Report Form

Please complete the following information.

I choose to remain Anonymous

I choose to share my contact information with the IHS Hotline and IHS Management Officials.

Contact Information is Optional

For your privacy and those you may be contacting IHS on behalf of: DO NOT include Personally Identifiable Information (PII) or Protected Health Information (PHI). Examples of PII and PHI are your phone number, address, health condition, social security number, date of birth (DOB), patient name (if not your own) and patient registration number. PII and PHI are protected by the Health Insurance Portability and Accountability Act and the Privacy Act.

Full Name:

Email:

Phone:

Organization:

Summary of Allegations:

Who? Identify the person(s) and/or entity(ies) involved.

What? Describe your allegation. Include specific detail in order to evaluate the allegation. Do you believe it is fraud, waste, abuse or mismanagement? Do you believe it is a criminal violation?

Where? Identify the IHS Area, facility or location where the alleged actions occurred. Is the facility federally or tribally operated?

When? Identify a time frame(s) for the allegation(s). Provide specific dates if known.

Describe how you became aware of these actions:

Are you aware of witnesses to the allegation? Please identify.

Do you possess any documents or physical evidence to support the allegation?

Have you reported this allegation to anyone else? Please identify.

Do you believe you have been retaliated against for reporting this allegation? Please explain.

Please include any other pertinent information.

Report Form

Please complete the following information.

Summary of Allegations:

Please review all information before you submit. Please do not submit multiple reports for the same instance.