Office of Inspector General

Complaint Form (Your specific contact information)

First Name:

Last Name:

Email Address:

Home Mailing Address:

City:

State:

Zip:

Phone Number:

()-

Work Address:

City:

State:

Zip:

Phone Number:

()-

Are you a current employee, former employee, or applicant for a position with a State Agency or a State Agency’s contractor?
Yes No

	I am reporting this matter under CFOP 180-4
	I am requesting protection afforded under the Whistle Blowers Act (s. 112.3187 - 112.3189, Florida Statutes).

Has this issue been reported to any other party?
Yes No

If Yes, Whom? When did you contact this person and what were the results? :

Information about the Employee, Individual or Provider who is the subject of this complaint :

First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone:

()-

Select the Office, Circuit/Region and County in which the person(s) are employed by using the following drop down boxes. If you are not sure of the correct location, select "I Don't Know" from the list.

Office/Program

Circuit/Region:

County:

Select suspected violation (select all that apply)

	Falsified official records
	Created false or ficticious client files
	Wrongful use of position, employees, or equipment for personal gain
	Wrongdoing by management
	Retaliation against an employee
	Revealed confidential information
	Improper use of public money
	Contract fraud
	Did not follow laws, rules or policies when making a contract or purchase
	In contracts or making purchases the employee takes bribes, makes illegal bids, receives awards or fails to monitor a contract, has a conflict of interest or disobeys a rule

When submitting a complaint, please be as specific as possible. Give the name(s) of the DCF employee(s) or service provider who committed a wrongdoing such as falsification of records, fraud, waste, or mismanagement of State personnel, equipment, or monies. State exactly what happened. Provide witness' names and how to contact the individual(s), if known. Do you know the location of any records or documents to support your complaint? If so, please provide details of what they are and where they are located.:

Complaints must be submitted in writing and will be reviewed upon receipt. A determination will be made either to open an investigation or submit to the appropriate office for handling. The more specific information that you provide us, the better we are able to assist you.

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