Office of the Auditor General Inspector General
COMPLAINT FORM
Please type or clearly print information.
Information
About Complainant:
Your name
(Required): ______________________________________ Date:________________
Address:______________________________________________________________________
Street Address
_______________________________________________________________________
City State
Zip
Code
Please
check one or more preferred methods of contact:
Home
Phone: ___________________________ Business Phone:______________________
Other
Phone:____________________________ E-mail:_____________________________
Please be aware that, because the
Inspector General is required to conduct its investigative work in a
confidential manner, those individuals who file complaints are not normally
informed of the existence, status or outcome of an investigation that may
result from their complaint. After you file a complaint with the Inspector General, you
will receive an acknowledgment letter. The acknowledgment letter will identify
a file ID number for your complaint. 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.
Are you a State of
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:
Your identity as
the person reporting an alleged violation is confidential unless you waive
confidentiality or unless required by law. 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.
Allegations, pleadings, and related documents are generally 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
appropriate prosecutor 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:
Office of the Auditor
General Inspector General
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:______________________________________Date:_______________________