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2020 NSAA Excellence in Accountability Award
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Fraud/Waste/Abuse Allegation Form
Step 1 of 6
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1. What type(s) of fraud, waste, or abuse are you reporting? (Check all that apply.)
Fraud:
*
Theft or misuse of State resources
Purchasing or procurement
Corruption (bribery/kickback)
Contract or grant management
Financial statement
Public assistance
Work injury
Unemployment
Health care
Waste:
(Intentional or unintentional, thoughtless, or careless expenditure, consumption, mismanagement, use, or squandering of State resources. Waste also includes incurring unnecessary costs because of inefficient or ineffective practices, systems, or controls.)
Abuse:
(
Government Auditing Standards
defines abuse as behavior that is deficient or improper when compared with behavior that a prudent person would consider reasonable and necessary business practice given the facts and circumstances. Abuse also includes misuse of authority or position for personal financial interests or those of an immediate or close family member or business associate.)
Other:
2. Which State government agency or entity is involved in your allegation?
*
Agriculture and Rural Development
Attorney General
Civil Rights
Civil Service Commission
Corrections
Education
Environmental Quality
Health and Human Services
Insurance and Financial Services
Judiciary
Legislature
Licensing and Regulatory Affairs
Military and Veterans Affairs
Natural Resources
Secretary of State
State Police
Talent and Economic Development
Technology, Management, and Budget
Transportation
Treasury
Other (list below)
Other State government agency or entity:
3. Does your allegation involve an individual person or entity doing business with a State agency, such as a contractor or grant recipient?
*
Yes
No
4. Name and position of the person(s) involved in the inappropriate activity:
5. When did the suspected loss or inappropriate activity occur?
6. Do you believe the suspected loss or inappropriate activity is still occurring?
*
Yes
No
7. What is the suspected amount of loss, if any?
8. Use as much detail as possible to describe the activity that you believe was inappropriate (include what, where, why, and how):
*
9. Please identify any specific law, rule, or other standard you think this activity violated:
10. When and how did this activity come to your attention?
11. Do you have any documentation or evidence to provide that supports your allegation?
*
Yes
No
Documentation can be invoices, vouchers, receipts, payroll records, etc. Describe the specific items we should review and provide copies. Copies may be scanned and uploaded using the buttons below or mailed to the address at the end of this form.
File
File
File
File
12. Has your allegation been reported to any other individuals or entities, such as department management, a law enforcement agency, a lawyer, or others?
*
Yes
No
If yes, please provide the name of the individual or entity, date filed, tracking number (if available), and status to date or outcome (if known).
13. Please provide identifying information for anyone else who may have witnessed or be aware of the incidents being described (name, e-mail address, phone number, etc.):
14. If there is any other information useful to our review of your allegation that has not already been submitted, please provide it below:
Optional Information About You:
First Name
Last Name
Phone
E-mail
Street Address
Address Line 2
City
State
Zip Code
What is the best time frame for us to contact you if we need to?
Morning
Afternoon
Evening
Specific time frame:
What is the best method for us to contact you if we need to?
Phone
E-mail
Letter
Email
This field is for validation purposes and should be left unchanged.
