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2. Your Name*
4. Phone Number*
6. Brief description of concern*
8. Member/Family Member you are concerned about*
10. Can we share your name with the employee? *

    1. Yes
    2. No
12. Code of Concern (refer to cheat sheet)?*

    1. Green
    2. Yellow
    3. Orange
    4. Red
14. We intend to follow up with concerns within 48 hours. Does this concern need more immediate attention?*

    1. Yes
    2. No
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16. Submit

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