TransEnterix, Inc.

This form should be used to document a matter, as described in the Business Code of Conduct, that you feel needs to be addressed by The Board of Directors or senior management of your company.

Please remember this is a voluntary process and you should supply only information you know is factual. If you would rather speak to one of our specialists who will assist you, please call 888-335-9501 (English/Spanish). Any questions can be addressed to our service provider, The Compliance Partners (TCP), at transenterix@signius.com.

This is a confidential, anonymous process established for your protection. However, at the end of the process, you will be asked for your contact information. You are under no obligation to provide it. If you do, only The Compliance Partners will have access to this information, not your company. Only The Compliance Partners will contact you, should additional information be needed to address the matter you are reporting.

After this process is completed, The Compliance Partners will forward a confidential report of this matter to the appropriate parties about which you are providing information.
  1. Which company would you like to provide information about today? (required)

  2. TransEnterix, Inc.

  3. Is this the first time you have contacted us about this incident, either through phone, e-mail, fax, letter or the web?

  4. Yes
    No

  5. Are you contacting us to update information you have previously given us?

  6. Yes No

  7. Previous reference number(s), if any. If there are multiple reference numbers, please separate them with commas.



  8. Please describe your relationship with the company about which you are contacting us. Which of the following are you?



  9. If "other," please specify.



  10. What type of situation are you going to provide information about today?



  11. Do you know the location(s) where this is occurring?

  12. Yes
    No

  13. Please list the location(s), if any are known.



  14. How many individuals are involved in this situation?

  15. 1
    2-5
    5 or more
    Not sure

  16. Do you know the name(s) of the individual(s) and their position(s) within the company?

  17. Yes
    No

  18. Would you provide the name(s) of the individual(s) and their position(s) within the company?

  19. Yes
    No

  20. If yes, please provide as much of the following info (names, contact info, relationship to the company, name of the department s/he works in, if a vendor or competitor state the company for which they work) below.



  21. Please explain, in as much detail as possible, the facts of the incident -- who, what, when, where, why and how -- (required).



  22. Have you discussed this incident with a member of company management?

  23. Yes
    No

  24. Would you provide the name(s) of the individual(s), their position(s) within the company, the department s/he works in, and the date(s) you discussed this?

  25. Yes
    No

  26. If yes, please provide manager info including name(s), department(s) and date(s) discussed.



  27. Do you have any documentation, evidence or other material which you can provide or that can be obtained to assist in the review of this matter?

  28. Yes
    No

  29. If yes, please give a description of documentation, evidence or materials. If there is any, please send it to us via one of the following ways:



  30. Is there anyone else we can contact who may be able to provide additional information about this matter?

  31. Yes
    No

  32. If yes, please provide their name(s) and contact information.



  33. Would you like to receive feedback about this matter?

  34. Yes
    No

  35. This is a confidential, anonymous process established for your protection. You are under no obligation to provide us with your contact information. If you choose to provide it, TCP, not your company, will contact you should additional information be needed to resolve an issue. For our records, would you be willing to give your name?

  36. Yes
    No

  37. First Name



  38. Last Name



  39. Employee ID or badge number, if applicable.



  40. Street Address 1



  41. Street Address 2



  42. City



  43. State/Province/Other



  44. Zip Code



  45. Country



  46. Home Phone



  47. Work Phone



  48. Cell Phone



  49. E-mail Address



  50. If necessary, would you allow a representative of The Compliance Partners to contact you during the review process?

  51. Yes
    No

  52. By which method would you like to be contacted?



  53. If "other," please specify.


If you are having trouble with the form, please contact tcpsupport@signius.com.
You can also speak to one of our specialists who will assist you by calling 888-335-9501 (English/Spanish) .