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American Family Children's Hospital
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Vendor Incident Report Form

Contact Information
 
(608) 890-8505
(608) 890-8507 (fax)
 
Location
 
600 Highland Ave.
Rm: G5/146
Mailcode: 1639
Madison, WI 53792-1639
 
Hours
 
M-T, 8am-4:30pm
F, 8am-2:30pm

The Vendor Incident Report Form is made available to report violations of UW Health Policy 11.19. All reports of vendor representatives violating the policy will be investigated by the UW Health Vendor Liaison Office.

 

While this form requires contact information from the person reporting the violation, rest assured that your identity will not be revealed to anyone. The contact information is needed for the staff of the Vendor Liaison Office so we can follow-up with you both with questions about the incident you are reporting, and to let you know how the situation was resolved.

 

As noted in the policy, the following disciplinary process will be followed for those representatives found in violation of UW Health 11.19:

  • First Infraction: A letter of reprimand will be sent to the representative and the representative's immediate supervisor.
  • Second infraction: A second infraction will result in the loss of hospital privileges for a period of six months.
  • Third infraction: A third infraction will result in the representative being permanently barred from conducting business at UW Hospital and Clinics.
 
Person Reporting Incident
 
First Name:
 
Last Name:
 
Work e-mail Address:
 
Work Phone Number:
 
Work Address/Location:
 
 
Incident Information
 
Location of Incident:
 
Date of Incident:
 mm/dd/yyyy
 
Time of Incident:
 
Vendor Name:
 
Company:
 
Please describe the incident, including as many details as possible about what happened, when, where and under what circumstances:
 
 
  
 
 
 
 
Please note: This form should be used only for reporting Vendor incidents in regards to Policy 11.19. Please do not use this form for any other type of incident reporting.