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Fraud, Waste and Abuse Reporting

2. Tell Us About the problem
   Please complete the form below including as many details as possible. To correctly review your allegation, it is important to provide as many details as possible, including who, what, when, where, why and how.

   Please complete the form below including as many details as possible. To correctly review your allegation, it is important to provide as many details as possible, including who, what, when, where, why and how.

4. Type of Suspected Fraud Waste or Abuse

   1. Computer Misuse
   2. Contracts
   3. Procurement Violation
   4. Falsifying Records

   1. Insurance Fraud
   2. Theft
   3. Misuse of Equipment
   4. Safety

   1. Personnel Fraud
   2. Payroll Fraud
   3. Other (describe below)

   Select the applicable issues

6. Department or Agency Involved

8. Name of Person Involved, if known

10. When did the issue occur?

12. Estimated Amount of Loss

    1. Unknown
    2. $0 - $500

    1. $500 - $1,000
    2. $1,000 - $10,000

    1. $10,000 - $50,000
    2. More than $50,000

    Please select one

14. Description of the Fraud Waste or Loss

    Please provide any details that will help us investigate this matter.

16. May we contact you?

    1. Yes
    2. Yes, but keep my report confidential.

    1. No. I would like to stay anonymous.

    To thoroughly review this report, we may want to contact you for additional information. We will take appropriate precautions to keep your report confidential. If we may contact you, please complete the fields below.

18. First Name

19. Last Name

21. Primary Phone Number

22. Alternate Phone Number

24. Email Address

26. Address

28. City

29. State

30. Zip Code

32. Contact Instructions

    If appropriate, please include specific instructions on how to contact you. Indicate the best time to reach you and the preferred phone number.

Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

* indicates a required field