This form is intended to be a means to report a Code of Conduct violation that is not urgent enough to contact an AMIA staff member or Board member listed on the event website.

If anonymous, your complaint will be considered and tracked as a part of event history and general knowledge for the organization. These messages may be read by the AMIA Board of Directors and AMIA staff members and are treated in a confidential manner.

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* 1. Your name (optional)

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* 2. Email (optional)

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* 3. Date of alleged Code of Conduct violation

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* 4. Event or online forum name (AMIA affiliated only)

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* 5. Details about the alleged violation, the complaint, parties involved, and what occurred, and what part of the Code was alleged to have been violated.

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* 6. Do you want to be contacted to follow up on the complaint?

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