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TTUHSC Alternate Reporting Form

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APPLICATION FOR ISSUANCE OF SUBPOENA

JD-CL-136 Rev. 1-17

P.B. § 7-19; C.G.S. § 52-161b

Note to Applicant:

If you submit this application and it is denied in whole or in part, you may submit a Request for Hearing on Denied Application for Issuance of Subpoena (form JD-CL-137).

Instructions to Clerk:

If a self-represented applicant in any Civil, Family, Family Support Magistrate or Housing case has been convicted of a family violence crime or of any of the other statutes listed in the Application section and is seeking to subpoena the victim of such crime, schedule a hearing and give the applicant notice of the date, time and location of the hearing. Do not schedule such hearings for Criminal matters.

STATE OF CONNECTICUT

SUPERIOR COURT

JUDICIAL BRANCH

www.jud.ct.gov

COURT USE ONLY

AISBPPP







Type of Court Case

Application

I am a self-represented party in the case named above and I want to require the person or people listed below to testify in this case. I think that the testimony is necessary and ask that the judge or family support magistrate in this case review this application without notice to the other parties in this case. If this case has not been assigned to a specific judge or family support magistrate, I ask that the administrative judge or any judge or family support magistrate designated by the administrative judge review my application without notice to the other parties in this case. If the judge or family support magistrate decides that the subpoena(s) should be issued, I ask the judge or family support magistrate to have the clerk of the court issue the subpoena(s).

I understand that I have to give any subpoena(s) issued to a state marshal (an individual authorized to serve the person(s) being subpoenaed) or other authorized person and I must pay the state marshal or other authorized person a fee for serving the subpoena(s) unless the court determines that I am financially unable to pay for such expenses.

To Applicant: (Answer the questions below unless the case that you want to subpoena a witness for is a criminal case in which you are the defendant. If you are the defendant in a criminal case, skip to the next section.)

State whether you have been convicted of a family violence crime (C.G.S. § 46b-38a), risk of injury to children (C.G.S. § 53-21), sexual assault (C.G.S. §§ 53a-70, 53a-70a, 53a-70b, 53a-71, 53a-72a, 53a-72b or 53a-73a), or stalking (C.G.S. §§ 53a-181c, 53a-181d or 53a-181e.)

If yes, are you asking to subpoena the victim of your crime?

Name(s) and Address(es) of Person or People I am Asking to Subpoena



I believe testimony from this person is necessary because: (Fill in this box)

I believe that the person will testify that (state what you believe the person will say in court):

I want this person ordered to bring the following item(s) to Court:



I believe testimony from this person is necessary because (Fill in this box)

I believe that the person will testify that (state what you believe the person will say in court):

I want this person ordered to bring the following item(s) to Court

Type of Proceeding(s) I am Requesting Subpoena(s) For ("X" appropriate box)





Order

Having conducted a review of this application pursuant to Practice Book Section 7-19, and having considered the nature of the scheduled proceeding and future opportunities for examination of witnesses, the application is:

Having granted the application, the clerk of this court is directed to issue the subpoena(s):



JD-CL-136 Rev. 1-17

ADA NOTICE

The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.

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What the TTUHSC Alternate Reporting Form Is

The TTUHSC Alternate Reporting Form is an internal reporting instrument used by Texas Tech University Health Sciences Center to record incidents, personnel substitutions, or delegated responsibilities when the primary reporter is unavailable. It standardizes the alternate reporter's identity, date and time of the event, relationship to the affected party, and a concise description of the circumstances. The form supports consistent routing, review, and retention within institutional compliance workflows and facilitates timely notification to relevant departments such as risk management, human resources, or research compliance. Use of the form helps ensure documentation accuracy and auditability for later review.

Why a Standard Alternate Reporting Form Matters

The TTUHSC Alternate Reporting Form reduces ambiguity by capturing who will act in place of the primary reporter and records essential incident details for compliance review. Standardizing alternates improves response coordination, preserves chain-of-custody evidence, and supports institutional audits and corrective actions.

Why a Standard Alternate Reporting Form Matters

Who Completes and Relies on This Form

Primary users include departmental supervisors, compliance officers, and designated alternates responsible for accurate incident reporting and follow-up.

  • Departmental supervisors who authorize alternate reporters and verify incident details before routing.
  • Compliance and risk management teams that review submissions and monitor corrective actions.
  • Human resources for personnel issues and research compliance for protocol deviations.

Core Elements a Professional Form Should Include

A professional TTUHSC Alternate Reporting Form includes clear identifiers, concise incident description, authority delegation, signature fields, routing instructions, and space for attachments or supporting documentation.

Identifiers

Include full legal names, institutional IDs, department, and contact information for both primary and alternate reporters to avoid identity confusion during investigations and record retrieval.

Incident Summary

Provide a factual, concise description of the event, including date, time, location, and immediate actions taken. Avoid opinions; focus on observable facts.

Delegation Details

Specify the exact responsibilities the alternate will assume, any limits on authority, and duration of delegation to ensure operational clarity and accountability.

Signatures

Designate signature blocks for alternates, supervisors, and compliance reviewers. Include signature dates and roles to create a clear approval trail.

Routing

List routing recipients and expected timelines. Automated routing reduces delays and ensures the report reaches risk management and HR as required.

Attachments

Allow uploads or references to supporting files such as incident photos, witness statements, or medical reports; label attachments for easy cross-reference.

Step-by-Step: Completing and Routing the Form

Follow these steps to complete the TTUHSC Alternate Reporting Form accurately and ensure timely routing within institutional systems.

  • 01
    Prepare Details: Gather names, dates, incident summary, and contact information.
  • 02
    Identify Alternate: Record alternate reporter name, role, and relationship to the incident.
  • 03
    Sign and Date: Alternate and supervisor must sign and date in MM/DD/YYYY format.
  • 04
    Submit: Route to compliance office and retain a copy for records.

How the Form Moves Through Institutional Workflows

This flow summarizes how the TTUHSC Alternate Reporting Form moves from completion to review and final disposition within institutional systems.

  • Upload: Attach completed form and supporting documents.
  • Assign: System assigns to reviewer based on department.
  • Review: Compliance evaluates details and requests follow-up.
  • Close: Final disposition recorded and copies retained.

Recommended Digital Workflow Settings

Configure digital workflows to capture fields, route approvals, and store audit trails for the TTUHSC Alternate Reporting Form.

Field Configuration
Authentication Email link by default; enable SMS or KBA for high-risk cases.
Routing Sequential routing to supervisor then compliance office.
Storage Encrypted document store with version history.
Notifications Automated email reminders for pending signatures.

Technical Requirements for eSubmission

For eSubmission, ensure your platform supports secure PDF uploads, audit trails, and authenticated signer identity options.

  • File Types: Accepts PDF and Word DOCX formats.
  • Integrations: Works with Google Workspace and Microsoft 365.
  • Mobile Access: Signatures supported on desktop and mobile.

Security and Compliance Essentials

In-transit Encryption: TLS 1.2/1.3 protects data during transfer.
At-rest Encryption: AES-256 encryption for stored documents.
HIPAA Compliance: HIPAA-compliant workflows; BAA required for vendors.
Audit Trail: Detailed timestamps, IP addresses, and action logs.
Access Controls: Role-based permissions and authentication options.
Certifications: SOC 2 Type II, ISO 27001, PCI DSS available.

Penalties and Risks of Incorrect or Incomplete Forms

Incomplete Information: May invalidate report.
Late Submission: Risk of disciplinary action.
Wrong Signatory: Document may be rejected.
HIPAA Breach Risk: Potential civil and criminal penalties.
Loss of Evidence: Compromises investigations.
Regulatory Fines: Agency penalties possible.

Common Preparation Pitfalls to Avoid

  • Failing to include alternate contact details often delays investigations and forces repeated outreach to confirm responsibilities and timelines.
  • Using informal role descriptions rather than official titles causes ambiguity when enforcing corrective actions or escalating incidents to higher authorities.
  • Copying information by hand from other records increases transcription errors, which can affect compliance reporting and legal defensibility.
  • Not saving a timestamped digital copy or audit trail can undermine the record's evidentiary value during audits or external reviews.

Typical Processing Deadlines and Expectations

Key timing expectations for completing and processing the TTUHSC Alternate Reporting Form are summarized below; follow local policy for precise deadlines.

Immediate Notification:

Report as soon as the alternate is designated, ideally within 24 hours.

Internal Review Window:

Complete initial review within 5 business days.

Corrective Action Timeline:

Implement and document corrective steps within 30 calendar days.

Record Retention Start:

Retention begins on form submission date.

External Reporting:

Notify external agencies when legally required per incident type.

eSignature Pricing and Feature Comparison for Form Processing

The table compares common eSignature plan features and pricing relevant to processing the TTUHSC Alternate Reporting Form.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8 per user per month (annual billing) $15 per user per month (annual) $14 per user per month (annual) $19 per user per month (annual) $15 per user per month (annual)
Free Trial 7-day free trial, no credit card required Trial terms vary by vendor and plan Trial terms vary by vendor and plan Trial terms vary by vendor and plan Trial terms vary by vendor and plan
Bulk Send Available on select plans, including bulk send features Available on paid plans with limits Available on paid plans Available on paid plans Not available on standard plans
Audit Trail Comprehensive audit trail with timestamps and IPs Comprehensive audit trail with timestamps and IPs Comprehensive audit trail with timestamps and IPs Comprehensive audit trail with timestamps and IPs Comprehensive audit trail with timestamps and IPs
HIPAA Compliant Yes, HIPAA support with BAA required Yes, HIPAA support with BAA available Yes, HIPAA support with BAA available No No
Envelope Cap No envelope cap for paid plans Limit of 100 envelopes per user per year Caps depend on plan Caps depend on plan Caps depend on plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about completion, submission, and legal validity of the TTUHSC Alternate Reporting Form are provided below.


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