MedTrust Staffing

Comment/Question/Complaint Instructions:

Today's Date (mm/dd/yyyy):

Nature of Complaint, Comment, or Question:

Detailed Descrition of Complaint, Comment, or Question
(inclue month,date, and year of incident):

1. Is this the first time you have submitted a complaint/comment/question
to MedTrust, LLC?

2. Is this the first anonymous complaint/comment/question you have
submitted to MedTrust, LLC?

YES

NO

YES

NO

If an employee has a complaint/comment/question they wish to submit anonymously to MedTrust,
LLC, they should complete the form below. This information is considered priveleged and
confidential and will not be shared with anyone outside of a need to know basis.

If the employee wishes to disclose contact information in step 2 of this form, they will be
responded to by the appropriate personnel for the inquiry within 24 hours, excluding weekends
and holidays.

If experiencing technical difficulties, employees may also utilize the Employee Hotline at
877-582-8167.

The questions below are strictly voluntary. The information below will be used for statistical
tracking purposes and will not be disclosed.

Copies of this document, enclosures thereto, and information therefrom will not be further released under penalty of the law due to its privileged and confidential nature.