Introduction:     The Rock County HSD Compliance Committee has created this form as a means to report concerns regarding non-compliance as outlined in the HSD MA Compliance Plan (Plan).  Please complete the form and include as much detail as possible in the Summary section.  All investigations will be completed in a non-retaliatory manor and a whistle blower clause in the Plan protects staff who report concerns in good faith.

Confidentiality and Anonymity is not requested.  If necessary, you may contact me for additional information and I do not place any restrictions on the release of my contact information.  Please fill out the contact form below.

I wish to remain Confidential.  You may contact me for additional information, but please keep my name confidential and do not share it outside of Rock County Human Services.  Our policy is to honor requests for confidentiality and not to release any data that would identify such individuals unless required to do so by order of law (e.g., court order/subpoena).  Please fill out the contact information below.

I wish to remain Anonymous.  By remaining anonymous, the reporter limits the capabilities of Rock County Human Services to investigate areas of concern.  It is important to note that we will not be able to contact you if we need additional information about your compliant and the results of any investigation.

Thank you for contacting the ADRC.