Fillable COMPLAINT (Your) Contact Information (Illinois)

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COMPLAINT (Your) Contact Information (Illinois)

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Form 300.4A (rev. February 2016)
Page 1 of 3
COMPLAINT
Please type or print clearly below. Return completed form to: Office of Executive Inspector General, Division of
Investigations, 69 West Washington Street, Suite 3400, Chicago, IL 60602. Alternatively, you may fax the form to
our office at (312) 814-5479. Our toll-free hotline number is (866)814-1113. TTY: 1-888-261-2734.
(Your) Contact Information
Name:*
*The OEIG accepts anonymous complaints
Age:
Sex:
Address:
Street Address
City State Zip Code
Home Phone: Business Phone:
Other Phone:
Email Address:
What is your preferred method of contact?
Are you employed by the State of Illinois, a State public
university, CTA, Metra, Pace, or RTA?
Date:
If yes, which agency?
www.inspectorgeneral.illinois.gov
M F
Yes No
Have you notified any other federal, State, or local agency of your
complaint or filed a lawsuit or grievance related to these matters?
If yes, with which agency did you file a complaint?
What is the complaint number?
Has your complaint been resolved?
Have you previously filed a complaint with the OEIG?
If yes, please list any known OEIG case numbers:
Is this complaint related to your previously filed OEIG complaint?
Yes No
Yes No
Yes No
Yes No
If yes, briefly summarize the results:
Job Title:
Is your complaint against an employee(s), agency, or someone doing
business with the State of Illinois, CTA, Metra, Pace, or RTA?
If yes, which agency?
Yes No
Form 300.4A (rev. February 2016)
Page 2 of 3
Subject Information (person(s) against whom you are complaining)
Subject's Name:
Phone:
Approximate Age:
Sex:
M F
Address:
Street Address
City State Zip Code
Agency Employed: Job Title:
Subject's Name:
Phone:
Approximate Age:
Sex:
M F
Address:
Street Address
City State Zip Code
Agency Employed: Job Title:
Subject's Name:
Phone:
Approximate Age:
Sex:
M F
Address:
Street Address
City State Zip Code
Agency Employed: Job Title:
Subject's Name:
Phone:
Approximate Age:
Sex:
M F
Address:
Street Address
City State Zip Code
Agency Employed: Job Title:
Additional Information:
Additional Information:
Additional Information:
Additional Information:
Please be aware that your complaint(s) may be referred to other government
agencies including the agency referred to in your complaint.
If your complaint is referred, do you consent to the release of your identity as the
complainant?
If the OEIG conducts an investigation and issues a report, do you consent to being
identified as the complainant in that report?
Yes No
Yes No
Form 300.4A (rev. February 2016)
Page 3 of 3
Please list other person(s) who could be a witness to the misconduct you have alleged:
Name
Any identifying information (Agency, Title, Telephone Number, etc.)
Name
Any identifying information (Agency, Title, Telephone Number, etc.)
Name
Any identifying information (Agency, Title, Telephone Number, etc.)
Illinois law provides that the identity of any individual providing information to an Executive Inspector General shall be kept confidential and
may not be disclosed without the consent of that individual or when disclosure of the individual's identity is otherwise required by law. 5 ILCS
430/20-90(a). Illinois law states that any person who intentionally makes, to an Executive Inspector General, a false report alleging misconduct
is guilty of a Class A misdemeanor. 5 ILCS 430/50-5(d).
Complaint Taken By:*
*To be completed by the OEIG
Complaint Information
Please summarize your complaint, including the date and time of alleged incident(s) (please attach any
documentation or other evidence in support of your complaint):
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Completed 28 October 2021

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