Complaint Reporting Form

Reporting Date:	Now
1. I am a:
2. Do you wish to remain anonymous?:	Yes (if yes, skip #11 of this form) No
When reporting fraud, waste, or abuse, you may remain anonymous if you wish. You are encouraged to identify yourself so that we may follow-up on your complaint via e-mail, telephone, or in person and obtain additional information that may be helpful to our review of the matter.
3. I request whistle-blower status:	Yes No
Note: You must provide your full FIRST and LAST name in order to be considered for whistle-blower status. (ONLY current employees or current contracted employees of the Consolidated Government may be granted whistleblower status, in accordance with Part 5, Chapter 602, Ordinance Code.) In order to be granted whistle-blower status your complaint(s) must allege an act or suspected act of gross mismanagement, malfeasance, misfeasance, gross waste of public funds, or gross neglect of duty committed by an employee or agent of an agency or independent contractor or any violation or suspected violation of any federal, state, or local law, rule, or regulation committed by an employee or agent of an agency or independent contractor which creates and presents a substantial and specific danger to the public’s health, safety, or welfare.

Please provide the following information about the person(s), department, agency, entity, contractor or vendor about which you are alleging committed waste, fraud, misconduct, mismanagement, or other abuse.

4. Who is (are) the subject(s) of your complaint?:
Include first and last name, job title, place of employment and addresses, if known.
5. Describe the incident/event you wish to report. Include specific dates, times and locations. Please be as detailed as possible.:
(You may email additional information to support this complaint, to include attachments, photos, etc. to: InspectorGeneral@coj.net )
6. Who else has knowledge of this incident/event?:
Include first and last name, job title, place of employment and addresses, if known.

7. What rule, regulation or law do you think the subject(s) violated?:
8. Please describe the efforts you have made to resolve this problem:
9. Have you previously contacted or do you intend to contact the Department or Agency directly responsible for this issue?:	YesNo
If yes, Department or agency contacted?:
Date:	Now
Provide the name of the person(s) you spoke with and the action taken by the office listed above, if any:

10. What outcome do you anticipate?:

11. If you are not requesting to remain anonymous, please provide the following:
Name:
Home Address:
City, State, Zip Code:
Work Phone (Area Code & Number):	( ) - Second three digits Last four digits
Home Phone (Area Code & Number):	( ) - Second three digits Last four digits
Email Address:

12. How would you prefer to be contacted?:
13. What is the best time M-F, between 8a.m. and 5 p.m. to contact you?:
14. Are you willing to be interviewed in order to provide further information?:	Yes No

Security Code:

City of Jacksonville

Please provide the following information about the person(s), department, agency, entity, contractor or vendor about which you are alleging committed waste, fraud, misconduct, mismanagement, or other abuse.

11. If you are not requesting to remain anonymous, please provide the following:

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