Compliance Incident Reporting

*This form is for security and incident PHI reporting. All other types should use our general contact form.

The form is secure, and is guarded by a single member within the company leadership team.  We attend to all messages with the same attention and care.

Please note you should avoid sensitive and identifying information in your note such as social security numbers and birthdates, but it also extends to simpler concepts like someone’s full name.  However, we encourage you to provide us with as much as you’re comfortable in sharing, and we would love your contact information in case we need to respond directly to you.  You can use the optional contact information field to provide us with a phone number or an email address – whatever works best for you.  Of course, you can complete the form anonymously by typing “Anonymous” in the contact name information field.

 

This form is used to report an incident, which may include, but is not limited to, unauthorized access to data, loss of data, data corruption, system infiltration, and malware attacks. It may involve financial data, company secrets, or patient data that may be regulated under HIPPA.

I confirm that I am an employee or contractor at Tribal Diagnostics, LLC.(Required)
Name
If you do not wish to share your name, please type Anonymous in both fields.
Please share the approximate date the incident occured.
MM slash DD slash YYYY
Please provide a detailed description of the incident you are reporting.
If you wish to upload any files, please do so here.
Drop files here or
Max. file size: 50 MB.