Sunrise Community, Inc. & Affiliates Compliance Reporting Form THIS SITE IS NOT A 911 OR EMERGENCY SERVICE.  Do not use this site to report events presenting an immediate threat to life or property.  Reports submitted through this service may not receive immediate response.  If you require emergency assistance, please contact your local authorities. This form is intended for all staff, vendors and stakeholders, to submit compliance concerns.  If you wish to remain anonymous, you are not required to enter personal information.  Sunrise respects your right to privacy, all information received will be kept confidential.  Are you a Sunrise Employee?       Yes       No    Do you wish to remain anonymous?       Yes         No If yes, go to Section II May we contact you for additional information?       Yes         No If yes, please complete the Section I
	SECTION I   First Name Last Name Middle Initial Title Organization Address 1 Address 2 City State Please Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip/Postal Code Work Phone E-mail     SECTION II   What is the nature of this concern/matter? Please Select Accounting or Auditing Matter Conflict of Interest Discrimination or Harrassment Embezzlement Falsification of Contracts, Reports or Records Misconduct or Inappropriate Behavior Sabotage or Vandalism Substance Abuse Theft Unsafe Working Conditions Violation of Policy Violence or Threat Other     Have you discussed this concern/matter with your supervisor?       Yes       No     SECTION III   Person/Issue Being Reported Please Select Vendor Employee/CoWorker Person/Consumer receiving services     Name/Issue Company Name Please Select Company 81-UCP of Greater Hartford, CT 83-TECH of Collier County, Inc, Naples 84-Sunrise Community of Polk Co, Inc 85-Sunrise Community Promotions, Inc 86-Sunrise Community of SW FL, Inc 88-Res. Independence of VA, Inc 90-Sunrise Community of Tennessee 91-UCP of Tallahassee, Inc 92-UCP of Sarasota-Manatee, Inc 93-Resources for Independence, AL 95-Sunrise Opportunities, Inc 96-Sunrise Northeast, Inc, CT 97-Sunrise Community, Inc <%=FP_FieldHTML(fp_rs,"Company")%> Location Please Select Location 081-UCP Hartford, CT 083-Naples 084-Daytona 084-Lakeland 084-Sebring 085-Sunrise Promotions 086-Arcadia 086-Cape Coral 086-Clewiston 088-Fairfax 090-Clarksville 090-Greenville 090-Knoxville 091-Tallahassee 092-Sarasota 093-Mobile 093-Tuscaloosa 095-Boca Raton 095-Brow-NDade 095-Haven 095-SOH 095-SOK 097-Corporate 097-St. Petersburg 097-Bartow/Green Tree Court 097-Sunrise Community North Dade/Broward ICF's 097-120 Person Facility 097-SOK ICFs 097-SOH ICFs 097-Tampa 097-Panama City 097-Tallahassee (North Florida ICFs) 097-Sonderling 097-Old Dixie 097-South Dade Station <%=FP_FieldHTML(fp_rs,"Location")%> Job Title (if applicable) Type of Incident Date of Incident Time of Incident Location of Incident     Incident Affected ( Check all that apply):     Self Employee Person/Consumer receiving services Other (Please explain)         Description of Incident   Compliance is conforming to established rules, regulations and policies.  It is ensuring that those who conduct business for or on behalf of Sunrise are demonstrating established ethical behaviors and upholding established standards as measured against commonly accepted rules of conduct for society or for a profession.  Sunrise is committed to conducting its business in accordance with all federal, state and local laws which govern its industry.  Sunrise can only meet this commitment through the diligent efforts of its employees. They must demonstrate behavior that reflects integrity, honesty and compliance with applicable legal and regulatory requirements.  Sunrise is committed to maintaining a work environment that promotes these principles and permits its employees to perform their daily task in a work culture with the utmost  professionalism. The Compliance Reporting Form is one of the tools available for reporting compliance issues and incidents that may include:  Conflicts of Interest Embezzlement or Fraud (Including Kronos) Ethical Standards Violations Medical Billing Irregularities Consumer Abuse Consumer Privacy Rights/Other Consumer Rights (HIPAA Issues) Consumer Safety Safety, Health and Environmental Violations/Concerns Policy Violations Substance/Alcohol Abuse Theft or Abuse of Sunrise  Property (Including Sharing of Passwords) Threats to Property Workplace Violence   While it is not the intent of the Compliance Department to replace current procedures for reporting issues to your supervisor or other managerial authority, it is the responsibility of all employees to report any violation of laws or ethical standards to which Sunrise must adhere.  In no event shall any individual who reports a concern be subjected to any retaliation related to a report which he or she reasonably believed to be true and offered in good faith.