WASHINGTON STATE UNIVERSITY                                                       Case No.: _______
OFFICE OF INTERNAL AUDIT                                                         Date of Log: _______

 STATE WHISTLEBLOWER PROGRAM: Whistleblower complaints received by the Office of
 Internal Audit are forwarded to the State Auditor’s Office Whistleblower Division for investigation within
 15 working days of receipt of complaint. The WSU Internal Audit staff may still perform investigation if
 preliminary procedures determine it is necessary, and/or an investigation may be performed by Internal
 Audit staff on behalf of the State Auditor’s Office. Once a claim has been investigated by either agency,
 and a report issued, the working papers and report will be public records, thus subject to Public Records
 Request. Questions on this Program may be directed to SAO (http://www.sao.wa.gov/) or Internal
 Audit, 509-335-2001.

1. Please provide your name and contact information. You are not required to provide this
information to file a claim – with no name, the claim is anonymous. However, providing
contact information will enable us to contact you to clarify the claim, and/or, report on
progress or results of the investigation.

Name: __________________________                       Contact: _______________________________

2. Please provide the name of the person(s) alleged to have engaged in employee
misconduct as defined at http://internalaudit.wsu.edu/Claim.html. If your claim is alleging
misconduct of more than one person, please include the following information for all:

Name: ___________________________         Position or Title: _________________________
Employing Department: ___________________________________________________________

3. Explain why you believe that the individual named above may have engaged in employee
misconduct, and what type of misconduct: fraud, abuse, ethics or policy violation, etc. Be as
specific as possible as to dates, times, places, and actions. Attach additional sheets of paper
if the space provided below is not sufficient.

4. Attach or make reference to any documents or other evidence that may support your
allegations. Also provide the names and addresses (if known) of any witnesses or persons
who may have knowledge of facts that support your allegations.

5. Please make note if you have submitted a claim to any other agency or department,
including State Auditor’s Office, Executive Ethics Board, or WSU department, which one,
and when.

Submit completed form (use additional paper if necessary) by email (hlopez@wsu.edu), fax (509)
335-5241, or mail (WSU Internal Audit, PO Box 641221, Pullman, WA 99164-1221).

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