Part IV – SIGNATURES
By signing below, I understand that information contained in the incident report will be held confidential to the extent possible. Information on this report may be shared with appropriate Burrell College of Osteopathic Medicine officials in order to conduct a thorough investigation, if necessary. I hereby declare that the information on this form is true, correct, and complete to the best of my knowledge. I understand that any misrepresentation of information may result in disciplinary action.