This form is for employees of companies, organizations, or agencies that subscribe to AlignHR's Share a Concern service.

If you are uncertain if your company, organization, or agency has an active subscription, please complete the company contact information and we'll verify that before replying to you.

Information provided on this form is confidential and is used to contact AlignHR, LLC designated advisors only.

To what company, organization, or agency does this report apply? : *

First Name: *

Middle Name: *

Last Name: *

Position: *

Phone: *	Contact Preference: * No Preference Phone Email
E-mail: *

Please Describe Your Problem: *

Are There Any Witnesses? : *
Yes
No
Not Sure

Who else would have knowledge of this matter? (Please include witnesses here):

Why are you reporting this issue?: *

Has this issue occurred in the past? : *
Yes
No
Not Sure

If so, who did you report it to within the company? :

May we contact you? : *
Yes
No

What is the best way to contact you? : *
Phone
Email
Other

Please Provide Your Contact Information: *

What is the best day and time to contact you? (Please provide more than one time): *

You may attach any files, pictures, etc., that you feel applicable by dragging and dropping them here:
(Acceptable Formats: .pdf, .png, .jpg, .jpeg)

By checking here, you agree to the following. This is required to submit this form.: *
By submitting this form I attest to the truth and accuracy of all statements made on my behalf. I also acknowledge that my employer has provided training on this "Share a Concern" program, and made me aware of the fact that there may be disciplinary action or legal action taken for intentional falsification in sharing a concern.

Terms and Conditions: *
By checking here, you agree that you have read, understand, and agree to the Share-a-Concern terms and conditions, and privacy policy. This is required to submit this form.