Fill - Free fillable COUNTY OF SAN DIEGO OFFICE OF ETHICS AND (County of San Diego) PDF form

Revised 5/12/17

COUNTY OF SAN DIEGO

OFFICE OF ETHICS AND COMPLIANCE

IMPROPER COUNTY GOVERNMENT ACTIVITY COMPLAINT FORM

The County of San Diego’s Office of Ethics and Compliance, herein referred to as “Office,”

is the official body of the County to investigate Whistle Blower complaints as authorized

under Government Code Section 53297. The Office advises the Board of Supervisors and the

Chief Administrative Officer on whether or not improper County government activities

occurred.

Specific procedures have been adopted for the express purpose of filing and investigating

complaints alleging improper County government activities. These procedures do not

supersede, replace or serve as an alternative to procedures under the County’s Civil Service

Rules, Memorandum of Agreement, or other County rules and regulations providing remedies

for employees who file complaints, grievances or claims.

An employee of the County, or applicant for County employment, can file a complaint with

the Office alleging improper County government activities. The complaint must be filed

within SIXTY (60) CALENDAR DAYS of the date the complainant had knowledge of the

alleged improper County government activity. The Office has no authority to provide any

remedy for the complainant.

Any reprisal action taken against County employees, applicants or witnesses, because of the

filing of a complaint, is strictly prohibited under Government Code Section 53298.

_________________________________________________________________________

INSTRUCTIONS FOR COMPLETING THE COMPLAINT FORM:

Please describe, under each appropriate category, the improper County government activity

which is the subject of this complaint. Please be clear and specific, as to the facts, only as

they relate to the improper County government activity.

Improper County Government Activity means any activity, or act by a County department,

officer (elected or appointed) or employee relating to the performance of official County

business, duties and responsibilities.

There are four categories that constitute improper County government activity: (1) gross

mismanagement, (2) significant waste of County funds, (3) abuse of authority, or (4)

substantial and specific danger to public health and safety.

Gross Mismanagement means the failure to exercise even a substandard level of

performance relating to the management of County programs, activities, functions, services

and responsibilities.

Revised 5/12/17

Abuse of Authority means the willful exercise of authority for improper or wrongful

purpose.

Your complaint must be a true and accurate account to the best of your knowledge, and you

must sign under penalty of perjury. In accordance with the County Administrative Code,

Article XVII-D, a copy of the complaint received by the Office shall be transmitted to the

respective department head(s).

Once the Office has reviewed and accepted your complaint, it will be investigated by an

investigator(s). If you move or change your phone number, remember to let the Office know.

If you have questions, please call the Office at (619) 531-5174.

RETURN THE COMPLAINT TO:

Office of Ethics and Compliance

1600 Pacific Highway, Room 400

San Diego, California 92101

Revised 5/12/17

1. COMPLAINANT: _____________________________________________________

Last Name First Name Middle Name

HOME ADDRESS:

_______________________________________________________________

No./Street Apt./Unit No. City State Zip Code

WORK ADDRESS:

_______________________________________________________________

No./Street Room/Suite No. City State Zip Code

TELEPHONE: ________________________________________________________

Home Work Message

EMAIL: _____________________________________________________________

2. ALLEGATIONS OF IMPROPER COUNTY GOVERNMENT ACTIVITY (List each

allegation under the appropriate category). If you need more space, please attach

additional sheets.

A. Gross Mismanagement

Date you had knowledge of allegation: _______________________________

1. Allegation: _______________________________________________

_________________________________________________________

2. Facts: ____________________________________________________

_________________________________________________________

B. Significant Waste of Funds

Date you had knowledge of allegation: _______________________________

1. Allegation: _______________________________________________

_________________________________________________________

2. Facts: ____________________________________________________

_________________________________________________________

Revised 5/12/17

C. Abuse of Authority

Date you had knowledge of allegation: _______________________________

1. Allegation: _______________________________________________

_________________________________________________________

2. Facts: ____________________________________________________

_________________________________________________________

D. Substantial and Specific Danger to Public Health and Safety

Date you had knowledge of allegation: _______________________________

1. Allegation: _______________________________________________

_________________________________________________________

2. Facts: ____________________________________________________

_________________________________________________________

WITNESS(ES): Please provide the name, address and phone number for each witness.

Attach additional sheets if needed.

___________________________________________________________________________

Revised 5/12/17

PLEASE DESCRIBE THE ADMINISTRATIVE REMEDIES TAKEN BY YOU TO

RESOLVE THE AFOREMENTIONED ALLEGATIONS OF IMPROPER COUNTY

GOVERNMENT ACTIVITY. (Please give dates and names).

___________________________________________________________________________

SWORN STATEMENT OF COMPLAINANT:

I hereby certify, under penalty of perjury as provided by law, that the statements

herein are true.

___________________________________________________________________________

Print Name Signature Date

Revised 5/12/17

AUTHORIZATION OF INVESTIGATION

AND

RELEASE OF RECORDS

Date: ___________________________

I, ____________________________________________, having alleged improper County

government activity by the Department of _______________________________________,

authorize the Office of Ethics and Compliance (OEC) and its authorized agents to investigate

said allegation(s), per Administrative Manual Item Number 0010-10. I hereby authorize the

County of San Diego, the Department of Human Resources, and the Department(s) of

___________________________________________________________________________

to release to OEC and its agents all County personnel, payroll, medical and other records

pertaining to me, for OEC’s inspection, recording and photocopying.

__________________________________

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