Online Compliance Form

Control # (HCEC use only)
Date of Incident*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Name

Optional
Phone Number
Email
Individuals Involved*
Description*
Provide a detailed description of the suspected non-compliant conduct (including specific concern, why you think it is a problem, dates, duration, and locations)
Are there others with knowledge of the problem?*
- Yes
- No
Who else is aware of this problem?
Have you reported this concern to anyone else?*
- Yes
- No
When did you report this concern?*
MM slash DD slash YYYY
Who did you report this concern to?

Optional
Provide specifics of the discussion with that person.
Please identify any documents pertaining to the issue (describe them and indicate where located).
How did you discover the problem?
Are you willing to meet with the Harris County Emergency Corps Compliance Officer to discuss further?
- Yes
- No
Please provide any additional Information, or questions you may have:
We will take reasonable measures to ensure the confidentiality of the information you provided. However, there may be circumstances when the disclosure of this information is necessary to complete an investigation.
Comments
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We will take reasonable measures to ensure the confidentiality of the information you provided. However, there may be circumstances when the disclosure of this information is necessary to complete an investigation.