Healthcare Sexual Misconduct Application

HEALTHCARE SEXUAL MISCONDUCT APPLICATION

Use this form to report alleged sexual misconduct involving a member of the healthcare workforce or facility staff and to request a formal administrative review, investigation, or supportive services. The information provided will be used to assess immediate safety needs, initiate an investigation where appropriate, and to obtain medical and mental health records necessary for investigatory purposes with the limited authorization below.

Reporting Party — Patient Information

Reporting Details — Incident Information

Date of Incident:    Time of Incident (approx.):

Evidence available: Photographs Video Medical records Other (describe below)

Medical and Support Services

Did you seek medical treatment for injuries related to this incident? Yes No

Do you currently desire mental health or counseling referral? Yes No

Previous Reports and Actions

Has this incident been previously reported to facility administration? Yes No

Has this incident been reported to law enforcement or another external authority? Yes No

Requested Remedy and Confidentiality Preferences

Requested actions (select all that apply): Administrative investigation No-contact or reassignment Counseling referral Disciplinary action Other (describe below)

Preferred method of contact for updates: Phone Email Mail

Authorization to Release Records and Consent for Investigation

I hereby authorize the release of my medical, mental health, and ancillary records, including but not limited to notes, diagnostic studies, photographs, and billing records, to authorized investigators and administrators for the limited purpose of investigating the allegations described in this application. This limited authorization includes release of records from any treating facility or provider relevant to the incident.

I understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance on this authorization. I further understand that revocation will not affect disclosures already made pursuant to this authorization.

I acknowledge that reports involving potential harm to others or suspected abuse of a minor may be subject to mandatory reporting to authorities as required by law.

Certification and Signature

I certify under penalty of perjury under applicable law that the information provided in this application is true and correct to the best of my knowledge and belief. I acknowledge that knowingly making a false statement may result in administrative or legal action.

By signing below I affirm that I am the patient identified in this form or the lawful guardian/representative of the patient and have authority to make this application on the patient’s behalf. If signing as a representative, state relationship to patient in the relationship field.

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