Patient Privacy | University of Utah Health Care

* Required Information

Information entered on this form is secure and is only available to authorized employees.

* Your First Name:

* Your Last Name:

Your Email Address or Your Phone Number is Required

* Your E-Mail Address:

* Your Phone Number:

Hour

Minute

AM / PM

Do you want your name kept confidential:

Yes

Incident Date:

Location of Incident:

* Details of Concern or Question:

If you are University of Utah Staff, Faculty, or Student:

Employee / Student ID:

Your Department: