Fillable USU Inspector General Complaint Form (Uniformed Services University Maryland)

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USU Inspector General Complaint Form (Uniformed Services University Maryland)

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USU Inspector General Complaint Form
PART 1: GENERAL INFORMATION
(a) Inspector General Act of 1978, as amended
(b) DoD Directive 5106.04, “Defense Inspector General”, May 22, 2014
(c) DoD Instruction 7050.7, "DoD Hotline Program," October 17, 2017
This form applies, but is not limited to, the following:
1. Violation of Laws, Rules or Regulations
2. Fraud, Waste or Abuse of Authority
3. Gross Mismanagement
4. Hostile Work Environment
5. Harassment
6. Research Integrity
7. Dangers to Public Health and Safety
8. Reprisal/Retaliation
9. Military Whistleblower Reprisal
To submit a complaint, please complete this form and email to: rebecca.jaworski@usuhs.edu.
Contact Information:
University Inspector General
rebecca.jaworski@usuhs.edu
(301) 295-1436 (o)
(301) 318-3734 (c)
Privacy Warning: We cannot guarantee your complete privacy when you use this form because complaints
transmitted via the internet cannot be completely protected from unauthorized attempts to access
information.
False Official Statement Warning: Use of this form constitutes a request for an official investigation of a person
you assert has engaged in wrongful conduct. It is a crime to knowingly make a false fictitious or fraudulent
statement or representation of material fact to induce government action. Knowing omission of a material fact
also is a crime (18 USC 1001).
If you would prefer not to fill out an online submission, you may use the fillable Acrobat format and submit
manually. Completed forms may be turned in or mailed to: Inspector General, Room A1040-X, 4301 Jones
Bridge Rd., Bethesda MD 20814.
PART 2: DETAILS OF YOUR ALLEGATION
1. Subject(s) - Who performed the wrongdoing? (All boxes in this form have been restricted to visible area only for
information input.)
a. Subject #1 First Middle
Last Name Name Initial
USU Inspector General Complaint Form
Subject #1 Duty Station/Place of Employment/
Business
(2). What did Subject #1 do or fail to do that
waswrong? Briefly describe the alleged
wrongdoing. Also, please attach any documents
that support your complaint.
(3). What rule, regulation or law do you think
Subject #1 violated?
b. Subject #2 First Middle
Last Name
Initial
Name
Subject #2 Duty Station/Place of Employment/
Business
(2) What did Subject #2 do or fail to do that
was wrong? Briefly describe the alleged
wrongdoing. Also, please attach any
documents that support your complaint.
USU Inspector General Complaint Form
(3). What rule, regulation, or law do you think
Subject #2 violated?
d. If there are more than two Subjects use this
area to provide the same information for each
Subject. (Full Name & Duty Station/Place of
Employment and (2) and (3) Above)
(Remember space is limited to visible
area.)
2. Witness(es)
Duty Station/
Last Name First Name MI Place of Employment/Business E-
Mail
USU Inspector General Complaint Form
3. When did the incident occur? Be as
specific as possible about the dates.
4.
Where did the incident occur? What
location or command, etc.
5.
Why do you think the incident took
place.
6. How have you tried to resolve the
problem?
7. Have you contacted your chain of
command?
No Yes
8. Have you contacted another
Inspector General?
No Yes
If yes, please identify the
command or agency and
provide the current
status of this matter.
If yes, please identify the
IG office and provide the
current status of this
matter.
USU Inspector General Complaint Form
9. Have you tried to resolve your
complaint using an established
process such as informal Resolution,
EO/EEO, or legal system?
No Yes
10. What do you want the IG to do?
If yes, please identify the
agency or office and
provide the current
status of the matter.
11. Additional information you wish to provide.
USU Inspector General Complaint Form
12. May we contact you?
Yes, contact me for more information. I have provided my contact information below.
No, I wish to remain anonymous and have not provided you with contact information.
Yes, but I want my identity to remain confidential.
13. Your contact information
:
Last Name First Name MI
Office Telephone (Area Code and number)
Email Address:
Duty Station/Place of Employment/Department
Submission Date:
Signature:
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USU Inspector General Complaint Form (Uniformed Services University Maryland)

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Completed 28 August 2020

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