OIG Contractor Reporting Form

This form is provided as a convenience to allow contractors to comply with the reporting requirements in the December 12, 2008, FAR amendment, 73 Fed. Reg. 67064. Specifically, contractors may use this form to satisfy the requirement that they notify, in writing, the National Labor Relations Board (NLRB) Office of the Inspector General, whenever the contractor has credible evidence that a principal, employee, agent, or subcontractor of the contractor has committed a violation of the civil False Claims Act or a violation of Federal criminal law involving fraud, conflict of interest, bribery, or gratuity violations in connection with the award, performance, or closeout of a contract or any related subcontract. The individual completing this form must be an authorized representative empowered to speak for the contractor. After you submit the form data, you will see a report confirmation screen that you print for your records. If you wish to provide information that does not fall within these guidelines, please visit the Inspector General Web page.

Instructions: Fill in the information below. If you are unsure if this form applies or you have any question., please contact Counsel to the Inspector General at OIG Hotline or call (202) 273-1960.

Your Company Information

First Name: *

Last Name: *

Your Title:

Your Business Email: *

Company Name: *

Business Address1: *

Business Address2:

Business State/Province: *

Business Zip/Postal Code: *

Business Country: *

Business Phone Number: *

Business Fax Number: *

Contract Information

Contract Number: *

My Company is the : *

Sub

Prime

I am reporting on : *

Prime

Sub

Please enter the following incident information:

Estimated Loss: *

Description of Loss: *

Initial Incident Date:

Is Incident Ongoing?: *

Date Learned of Violation:

Please provide a complete description of the facts and circumstances surrounding the reported activities, including the evidence forming the basis of this report, the names of the individuals involved, dates, location, how the matter was discovered, potential witnesses and their involvement and any corrective action taken by the company.

NOTE: Please provide only the names, business email contact, and business phone for any individuals involved and/or potential witnesses.

Comments Description: *

Agencies:

Please list any other government entities you are notifying about this incident:

Attachment:

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OIG Contractor Reporting Form

OIG Contractor Reporting Form

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