Statement of Purpose

The Ethics First Feedback Form is intended for use by Emeritus employees, residents, and customers to share their feedback including compliments, suggestions or concerns with the Emeritus management team. We encourage you to use this form to document matters which meet the descriptions identified in the drop down list provided on this form. This will provide Emeritus with relevant data to help us appropriately address your feedback.

The details of your submission can only be accessed by authorized users. You may be contacted for further information after further review of your submission.

Items marked with a diamond are required fields.

Your Information (If you want Emeritus to know your identity, please complete the following)

Do you wish to remain anonymous for this report?
(Select One)
Name & Contact Information
First Name
Last Name

Phone Number

Include the area code, extension,
and/or dialing codes if applicable.

Best time for communication with you:

Select the community your feedback is regarding:

You must use the “Look Up” function to select your “Community”. Click the button below labeled “Look Up”. The location & address information will be populated by the function.

Feedback Category

Feedback Category


What is your relationship to Emeritus?
(Select One)

Please identify the person(s) engaged in this behavior:
First Name
Last Name



Is management aware of this concern?
(Select One)

How long do you think this concern has been going on?
(Select One)

How did you become aware of this concern?
(Select One)


May Emeritus share your compliment with others? When sharing any feedback, Emeritus will maintain the anonymity of you and your loved one.
(Select One)

Please provide all details regarding the concern, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation.
(Please take your time and provide as much detail as possible, but exercise care to not provide details that may reveal your identity unless you wish to do so. It may be important to know if you are the only person aware of this situation.)


Re-Enter Password

(Passwords must be at least four(4) characters in length.)

Please provide a password for this report in the space above. Upon submission of this feedback report, you will be issued a 'report key'. Please write down your chosen password and report key and keep in a safe place – neither your report key or password can be recovered if you misplace them.

Using your Report Key and Password you can "Follow Up" on this report online by returning to in 3-5 business days and entering your Report Key and Password in the space provided. You can also "Follow Up" on this report by dialing toll-free (888) 529-5827.

Follow-up will allow you to:

  • Upload documents
  • Respond to follow-up questions/comments
  • Provide additional information