Complainant Information: First Name: Last Name: Your Work Email Address: Your Personal Email Address: Your Home Address: Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Cell Phone: Home Phone: Work Phone: Employer: Work Address: Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Relationship to the Institution Other… Enter other… How would you prefer we contact you? Work Phone Home Phone Cellular Phone Work Email Personal Email Other… Enter other… Are you a current employee of FSU or an FSU contractor? Yes No Are you a former employee of FSU or an FSU contractor? Yes No Are you an applicant for a position with FSU or an FSU contractor? Yes No Please provide information about the employee, individual, business or organization who is the subject of this complaint: Subject 1 Information (click to expand): Name: Address: Address City/Town State/Province ZIP/Postal Code Relationship to the Institution Other… Enter other… Phone Number: Subject 2 Information (click to expand): Name: Address: Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Relationship to the Institution Other… Enter other… Phone Number: Subject 3 Information (click to expand): Name: Address: Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Relationship to the Institution Other… Enter other… Phone Number: Additional Details Where did this violation/incident occur? When did this violation/incident occur? Is there a supervisor or a member of management involved? Yes No Other… Enter other… Is management aware of the problem? Yes No Other… Enter other… If yes, who? Has anyone attempted to conceal the violation/incident? Yes No Other… Enter other… If yes, who? How? Complaint Information: Please provide a detailed explanation of the alleged violation/incident to include information about exactly what the subject/s of the complaint did that you believe is a violation of FSU policy, procedure, to include an act of fraud, waste, abuse, or other dishonest acts. The information you provide should be specific and include names, dates, policy violations, if known, and other relevant details. Complaint Details How long has the violation/s been occurring? Is the violation still occurring? Yes No How did you become aware of this violation? Please provide the names of any witnesses to the allegations and contact information, if known. Has anyone else been notified about this complaint? If yes, who did you notify, when, and what was the outcome? Acknowledgement By clicking the “Submit Complaint” button below, you are affirming the information contained in this complaint is true and correct to the best of your knowledge. Upon receipt of your complaint, the Office of Inspector General Services will conduct a review of the information provided and additional information may be requested. The Office of Inspector General Services will notify you about the determination as to whether our office will initiate an investigation or potentially refer your complaint to another entity for review. Submit
