1. May we contact you?
Yes, contact me for more information. (Please provide your contact information)
No, I wish to remain anonymous. (Do not provide your contact information)
2. Contact Information: (All boxes in this form have been restricted to visible area only for information input)
Last Name First Name MI Rank/Grade
Your home or work address:
Home address Work address
Street 1:
Street 2:
State: Zip Code:
Home Telephone Number (incl area code)
Office Telephone Number (incl area code)
Mobile Telephone Number (incl area code)
E-Mail Address:
Duty Station/Place of Employment/Business
Yes, but I want my identity to remain confidential. (Please provide your contact information)
Yes No
3. Are you willing to be interviewed?
Who do you believe is responsible or performed the wrongdoing or inappropriate conduct?
4. Subject's Name
Duty Station/Place of Employment/Business
5. What did the person do or
fail to do that was wrong or
inappropriate? (Be specific)
(more space provided in block 13)
AUTHORITY: Title 10 U.S. Code 5014, Office of the Secretary of the Navy; 10 U.S. Code 5020, Naval Inspector General; SECNAVINST 5430.57
series, Mission and Functions of the Naval Inspector General; SECNAVINST 5370.5 series, DON Hotline Program.
PURPOSES: To determine the facts and circumstances surrounding allegations or complaints against Department of the Navy personnel
and/or Navy/Marine Corps activities. To present findings, conclusions and recommendations developed from investigations and other
inquiries to the Secretary of the Navy, CNO, CMC, or other appropriate Commanders.
ROUTINE USES: In addition to the disclosures generally permitted under 5 U.S. Code 552a(b) of the Privacy Act, the records contained
within may be specifically disclosed outside the DoD as a routine use pursuant to 5 U.S. Code 552a(b)(3) following the 'DoD Blanket
Routine Uses' that appear at the beginning of the Navy's Privacy Act System of Records notices.
DISCLOSURE: Voluntary. However, failure to provide the requested information may result in a lack of enough information for the
Inspector General to investigate or provide assistance.
6. What rule, regulation or law do you think
was violated?
7. When did the incident occur? Be as specific
as possible about the dates.
8. Where did the incident occur? What
location or command, etc.?
9. Why do you think the incident took place?
10. List any witnesses
11. What do you want the IG to do?
12. How have you tried to resolve the problem?
a. Have you contacted your chain of command?
No Yes
If yes, please identify the
command and the current
b. Have you contacted another Inspector General?
Yes No
If yes, please identify the IG
office and the current
If yes, please identify the agency
or office and the current status.
c. Have you tried to resolve your complaint using
an established process such as the grievance
process, EO/EEO or legal system?
No Yes
13. Additional Information
you wish to provide.
By submitting this form you certify that all of the statements made in this
complaint (including any attachments) are true, complete, and correct, to the best
of your knowledge. You understand that a false statement of a material fact is a
criminal offense (18 U.S.C. Section 1001).
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