WASHINGTON STATE UNIVERSITY Case No.: _______ OFFICE OF INTERNAL AUDIT Date of Log: _______ CLAIM TO REPORT EMPLOYEE MISCONDUCT 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 (firstname.lastname@example.org), fax (509) 335-5241, or mail (WSU Internal Audit, PO Box 641221, Pullman, WA 99164-1221).
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