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Compliance Referral Form

Helpful information regarding the completion of the Compliance Referral Form is available.

Keystone Human Services (Keystone) is committed to conducting its business with integrity and in accordance with all international, federal, state and local laws which govern its business. Moreover, it is Keystone's policy to prevent the occurrence of unethical or unlawful behavior, to halt such behavior after its discovery, to take corrective action with employees who violate Keystone's policies and procedures, including individuals whose failure to act may have condoned the violation or otherwise permitted the violation to continue, and to implement any changes in policy and procedure necessary to prevent recurrences of a violation.

Keystone can meet this commitment only through the efforts of our highly skilled and dedicated staff. It is they who must earn the trust and respect of the individuals we serve and others by continuing to conduct their business affairs with honesty, integrity and in compliance with the letter and spirit of all applicable laws. Although honesty and integrity are individual attributes, and each individual ultimately is responsible for his or her own conduct, Keystone is committed to maintaining a working environment that promotes these ideals and permits our employees and agents (independent contractors, consultants, etc.) to demonstrate the highest ethical standards in performing their daily tasks. Consequently, the Corporate Compliance and Integrity Plan, which includes the Code of Conduct, was established to detect and prevent violation of the laws, of which our organization must adhere.

Please be aware the Compliance Referral Form in no way diminishes or replaces the complaint/appeal protocol in place at each Keystone agency/subsidiary. In most cases, issues should initially be reported to your Supervisor or Agency Executive Director/CEO. However, certain issues should immediately be directed to the Compliance Officer or Agency Human Resources Department.

It is important to report the following issues to the appropriate department:
(This is not an all-inclusive list.)

Corporate Compliance Department Human Resources Department
Disclosure of Confidential Information (proprietary, competitive, or medical information) Alleged discriminatory practices to include potential EOE or ADA violations
Suspected employee fraud, misuse of funds or falsification of internal records, e.g. time sheets, encounter forms, claim forms/billing, and other information Alleged sexual harassment to include creating a hostile work environment.
Issues Related to our Government Contracts All issues involving use of drugs and alcohol while working
Misuse of Company Assets (which includes the sharing of passwords) Workplace Safety Issues (includes Occupational Safety and Health (OSHA) requirements and workplace threats and violence).
All issues of a legal, contractual, and/or regulatory nature Management Issues
Reporter's Information

As the person making this referral to the Corporate Compliance & Integrity Department it is important that we are able to contact you should we need additional information regarding this report. All information is held in strict confidence. Please complete the following information as it pertains to you the reporter.

This field is required.
  • Yes
  • No
Referral/Incident Information

The information below pertains to the reason for your referral. Please report who/what this referral is about; an individual receiving services, an employee, situation, incident, etc.


  • Complaint (to express dissatisfaction)
  • Consultative (to ask for an opinion)
  • Informational (to give facts or opinions)

  • Employee
  • Individual Receiving Services
  • Other (please list)
mm/dd/yyyy
  • AM
  • PM
  • Self
  • Employee
  • Individual Receiving Services
  • Other (please list)

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