EmailMeForm
Incident Reporting
Please take a moment to answer the below questions related to the incident you wish to report. All responses are anonymous unless you CHOOSE to leave your information. RRC will not retaliate against any individual who lawfully reports reasonable suspicion of a crime against a patient.
Your Name (Optional)
Your Email (Optional)
Your Phone Number (Optional)
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Do you want to be contacted regarding this issue?
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Please select
Yes
No
Facility of Incident
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Please select
Fort Worth
Round Rock
San Antonio
Waco
Date of the incident
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DD
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YYYY
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MM
AM
PM
AM/PM
What happened?
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Who was involved?
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Who else knows about what happened?
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Was management made aware?
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Please select
Yes
No
Manager aware of situation (or type N/A)
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