Healthcare Compliance Forms and Tools

Introduction

Introduce yourself and provide an explanation of the goal for meeting with the individual (i.e., to gather information that person may have).

Example: Thank you for taking the time to meet with me today. My name is John Doe, compliance specialist, and this is Jane Doe, HR business partner. We are gathering information related to a policy violation and believe you might have information that might be helpful. I will be asking the majority of the questions, and Jane will be taking notes. We have scheduled an hour for this meeting but can schedule more time if needed. Do you have questions?

Insert your introduction notes/comments here:

‍________________________________________________________________

________________________________________________________________

‍________________________________________________________________

Note: Please use this document as a reference tool and consult with your organization for preferred statements to provide as part of your standard interview script and proper processes to follow within your organization.

Confidentiality: You may want to consider describing to the interviewee your limits in keeping their information as confidential as possible. This may include an inability to promise complete anonymity due to needing to disclose information within the investigation team or to cooperate with other parties as required (i.e., regulators, government agencies, etc.).

Nonretaliation: You may want to outline your organization’s nonretaliation policy.

• Do you have any questions about confidentiality and nonretaliation?

• Do you agree to keep this meeting confidential?

• Do you have any other questions before we begin?

Confidentiality and Nonretaliation Notice Provided: Yes ☐ No ☐

Attorney-Led Investigations: Do you need to provide the Upjohn Warning? If yes, please see “Sample Upjohn Warning” for language.

Upjohn Warning Provided: Yes ☐ No ☐