Office of the Auditor General Inspector General

COMPLAINT FORM

Please type or clearly print information.

 

INSTRUCTIONS:

 

You are not required to provide information about yourself.  The Inspector General accepts anonymous complaints.  If you choose to provide information about your identity, there may be circumstances under which your identity may be revealed (for instance, if your complaint is referred to a law enforcement agency).  

Individuals who file complaints are not normally informed of the existence, status or outcome of an investigation.  Generally, you will only be contacted again if there is a need for additional information or clarification.

The Inspector General does not represent any party or agency in an investigation and does not investigate “on behalf” of any individual or agency. If an individual is seeking legal representation, she or he should consult with an attorney.

  

OPTIONAL INFORMATION:

Your name: ______________________________________ Date:________________

 

Address:______________________________________________________________________

Street Address

 

              _______________________________________________________________________

City                                          State                                                    Zip Code

 

 

􀂉 Phone: ___________________________

 

􀂉 E-mail:_____________________________

 

 

Are you a State of Illinois employee?     􀂉 Yes              􀂉 No

 

If “YES”, which agency?:_________________________________________________________

 

Is the alleged violation related to your State employment?                      􀂉 Yes              􀂉 No

 

 

INFORMATION ABOUT ALLEGED VIOLATION:

Is your complaint against an employee of the Office of the Auditor General?      􀂉Yes         􀂉 No

 

If “NO”, this office lacks the authority to review or investigate the alleged violation and the complaint will be returned or referred to the appropriate authority.  If “YES”, complete the following concerning the nature of the alleged violation.

 

Please provide as much detailed information as possible about the person who committed the alleged violation:

 

Subject’s Name:__________________________________ Phone:________________________

 

Title (if known):________________________________________________________________

 

Address:______________________________________________________________________

Street Address

              _______________________________________________________________________

City                                                                  State                            Zip Code

 

Have you notified any other Federal, State or local agency of your complaint or filed a lawsuit or grievance related to these matters?           􀂉 Yes              􀂉 No

 

            If yes, with what agency did you file a complaint?          ______________________________

 

            What is the complaint number?______________________________________________

 

Has your complaint been resolved?   􀂉 Yes                  􀂉 No

 

If yes, briefly summarize the results:________________________________________________

______________________________________________________________________________

 

May we refer your complaint to the appropriate agency if necessary?     􀂉 Yes              􀂉 No

Please be aware that complaints relating to management issues may be referred back to the agency.  Once your complaint is referred, you may be contacted by that agency as part of its investigation.

 

Please (1) describe the acts and circumstances that surrounded the alleged violation; (2) state the date and time of the alleged violation; (3) state the names of any other persons who witnessed or participated in the alleged violation; (4) provide any other relevant information; and (5) submit any relevant materials. (Add additional pages if necessary)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Other person(s) who could be a witness to the complaint you have alleged:

 

______________________________________________________________________________

Name  

______________________________________________________________________________

Any other identifying information (Agency, Title, Phone Number, etc.)

 

______________________________________________________________________________

Name  

______________________________________________________________________________

Any other identifying information (Agency, Title, Phone Number, etc.)

 

WAIVER OF CONFIDENTIALITY:

If you have identified yourself, your identity as the person reporting an alleged violation is confidential unless you waive confidentiality or unless disclosure is required by law or rule.  This right of confidentiality does not preclude the disclosure of the identity of a person in any capacity other than as the source of an allegation.

 

Do you wish to waive your right to confidentiality?         􀂉 Yes              􀂉 No

 

If “YES”, please sign here: _______________________________________________________

 

MATERIALS EXEMPT FROM DISCLOSURE:

The Office of the Auditor General's Inspector General's investigatory files and reports are confidential and exempt from disclosure under the Freedom of Information Act, but may be shared as permitted and appropriate for the proper conduct and conclusion of an investigation.  Upon conclusion of an investigation, a report regarding the investigation may be completed and provided to the head of the State agency responsible for managing the complaint or carrying out any recommended actions.  When supported by investigative findings, an investigative report may also be provided to the Attorney General or a law enforcement agency for review, to determine whether or not the underlying facts support a criminal prosecution.

 

WHERE TO RETURN THIS FORM:

Return completed form by mail to:

Don Kliment

Office of the Auditor General Inspector General

740 E. Ash St., Springfield, IL 62703

Phone: 217/782-6046; TTY:  888/261-2887

Please mark your envelope "confidential."

 

Any person who intentionally makes a false report alleging a violation of the State Officials and Employees Ethics Act to an ethics commission, an inspector general, the State Police, a State’s Attorney, the Attorney General, or any other law enforcement official is guilty of a Class A misdemeanor. 5 ILCS 430/50-5(d).

 

SIGNATURE (optional):______________________________Date:_______________________