OFFICE OF THE NAVSE
A INSPECTOR GENERAL
FRAUD,
WASTE,
ABUSE,
& MISMANAGEMENT COMPLAINT FORM
AUTHORITY: DoD Instruction 7050.01, SECNAVINST 5430.57 (series), SECNAVINST 5370.5 (series).
PRINCIPAL PURPOSE(S): To register a complaint relating to suspected Fraud, Waste, Abuse and/or Mismanagement.
ROUTINE USE(S): Data provided are furnished to supervisors, commanders or inspectors in response to queries for resolution of complaints and to eliminate
conditions considered detrimental to the efficiency or reputation of the United States Navy.
DISCLOSURE: Disclosure of your identity and any other personal identifying information is voluntary. Failure to provide the information will not adversely affect
the resolution of your complaint but may cause a delay in resolving the issue.
FALSE OFFICIAL STATEMENT WARNING: Use of this form constitutes a request for an official investigation of a person you assert has engaged in wrongful
conduct. It is a crime to knowingly make a false fictitious or fraudulent statement or representation of material fact to induce government action. Knowing
omission of a material fact is also a crime (18 USC 1001 and Art. 107 UCMJ).
We can only accept UNCLASSIFIED complaints via this form. Please go to www.dodig.mil to submit classified complaints.
SECTION I - YOUR IDENTITY
Anyone may file a complaint, regardless
of who you are, and you are not required to identify
yourself, exc
ept
f
or
al
legations of
repr
isal. In
order
to r
em
ain anonymous, do not provide any identifying information below. You may also elect to
remain confidential, or consent to the release of your identity and complaint outside of Navy IG channels.
If you remain anonymous, we will not be able to contact you to request additional information or provide you the status of
your complaint. Remaining anonymous will not in and of itself affect the disposition of your complaint, however, if we are unable to
reach out to you for additional information, we may dismiss your complaint.
We may also determine that your complaint should be referred outside of Navy IG channels, such as the chain of
command (e.g. the Commanding Officer). Unless you are anonymous, we need your consent to provide your identity and
complaint as part of our referral. If you wish to remain confidential and not provide your consent, we will provide a sanitized
summary of your complaint instead of your actual complaint. If you give us your consent we will provide your actual complaint but
redact your identity unless your identity is necessary to take action. If you wish to remain anonymous, we will provide your actual
complaint as part of the referral.
Regardless of your selection, we will make every attempt to safeguard your identity, but we cannot guarantee
confidentiality as we may be required to disclose your identity as part of an investigation, in the course of corrective action, as a
result of a decision of the NAVSEA IG or as required by any applicable law, rule or regulation.
I consent to the release of my identity and complaint outside of Navy IG channels.
I wish to remain confidential.
I wish to remain anonymous (proceed to Section III).
SECTION II - YOUR BIOGRAPHICAL INFORMATION (Skip if Anonymous)
Last Name First Name
MI
Street Address Line 1
Zip Code
City
State
Street Address Line 2
Country
E-mail (Personal)
E-mail (Work)
Home # Mobile # Work #
Your Status
Grade or Rank Organization (i.e. Dept/Division/Code, if applicable)
CONTROLLED UNCLASSIFIED INFORMATION
When filled out, this document is subject to controls by NAVSEA IG. Prior to release, please contact NAVSEA IG for permission.
How are you aware of
the Hotline Program?
Is the Chain of Command
aware of the complaint?
1
Gender
Please select one
Please select one
OFFICE OF THE NAVSEA INSPECTOR GENERAL
FRAUD, WASTE,
ABUSE, & MISMANAGEMENT COMPLAINT FORM
2
CONTROLLED UNCLASSIFIED INFORMATION
When filled out, this document is subject to controls by NAVSEA IG. Prior to release, please contact NAVSEA IG for permission.
SECTION III - SUBJECT INFORMATION (SUBMIT ADDITIONAL PAGES AS NEEDED)
SUBJECT 1
Last Name First Name
MI
Subject Status
Grade or Rank Organization (i.e. Dept/Division/Code)
SUBJECT 2
Last Name First Name
MI
Subject Status
Grade or Rank Organization (i.e. Dept/Division/Code)
SUBJECT 3
Last Name First Name
MI
Subject Status
Grade or Rank Organization (i.e. Dept/Division/Code)
Allegations Appropriate for an Inspector General
Please review the information below for examples of allegations that may be appropriate for a Navy Inspector General before proceeding.
- Abuse of Title or Position
- Bribes/Kickbacks/Acceptance of Gratuities
- Conflicts of Interest
- Ethics Violations
- False Official Statements/Claims
- Fraud
- Gifts (Improper receipt or giving)
- Mismanagement/Organization Oversight (Significant Cases)
- Misuse of Official Time, Gov’t Property, Position and Public Office
- Political Activities
- Purchase Card Abuse
- Reprisal (Military Whistleblower Protection)
- Safety/Public Health (Substantial/Specific)
- Systemic Problems
- Time and Attendance (Significant Violations)
- Travel Card Abuse
- Travel Fraud (TDY and TAD)
- Waste (Gross)
Please be aware that we are not a law enforcement agency. Any allegations of criminal wrongdoing should be sent to the
appropriate law enforcement agency, such as NCIS (www.ncis.navy.mil).
Please select one
Please select one
Please select one
OFFICE OF THE NAVSEA INSPECTOR GENERAL
FRAUD, WASTE, ABUSE, & MISMANAGEMENT
COMPLAINT FORM
SECTION IV - ALLEGATION INFORMATION (SUBMIT ADDITIONAL PAGES IF YOU NEED MORE SPACE)
What was done or not done that was wrong? Please be specific as you can, including which subject did what.
Where did this occur? Please be as specific as you can, including all locations and related information.
When did this occur? Please be as specific as you can, including all dates and times in chronological order.
How did this occur?
Why did this occur?
Who witnessed the wrongdoing? (Include first and last names, rank/pay grade, place of employment, etc.)
3
CONTROLLED UNCLASSIFIED INFORMATION
When filled out, this document is subject to controls by NAVSEA IG. Prior to release, please contact NAVSEA IG for permission.
What law, rule or regulation do you think was violated? (if known)?
OFFICE OF THE NAVSEA INSPECTOR GENERAL
FRAUD, WASTE, ABUSE, & MISMANAGEMENT COMPLAINT FORM
SECTION V - ADDITIONAL I
NFORMATION
Have you contacted another official, or do you intend to use another process, e.g., congressional, EEO, chain-of-
command or another IG to resolve this matter? If yes, please identify the official or process and the current status of
the matter.
Briefly describe how you believe this office can assist you with your complaint.
For each additional document you are providing, please provide a title, date, description of content, and its relevancy.
Have you read the "Allegations Appropriate for an Inspector General" description on the bottom of page 2?
No, I have not.
Yes, I have.
No, I do not.
Yes, I do.
By submitting this form, you c
ertify all statements made in this complaint are true, complete, and correct to the best of
your knowledge and / or belief. You understand that your complaint will not be reviewed if you fail to certify this
document by selecting the appropriate response below, or if you select the not certify option. You further
understand that a false statement or concealment of a material fact is a criminal offense (18 U.S.C. Section 1001;
Inspector General Act of 1978, as amended, Section 7; and / or the Uniform Code of Military Justice, Article 107).
This information is submitted for the basic purpose of requesting assistance, correcting injustices affecting the
individual, or eliminating conditions considered detrimental to the efficiency or reputation of the Navy.
No, I do not so certify.
Yes, I so certify.
Submit by Email
4
CONTROLLED UNCLASSIFIED INFORMATION
When filled out, this document is subject to controls by NAVSEA IG. Prior to release, please contact NAVSEA IG for permission.
Do you believe your allegations fall into the category of allegations appropriate for an Inspector General?
OFFICE OF THE NAVSEA INSPECTOR GENERAL
FRAUD, WASTE, ABUSE, & MISMANAGEMENT COMPLAINT FORM
SECTION VI
- PRIVACY ACT INFORMATION
DATA REQUIRED BY THE PRIVACY ACT OF 1974
PRIVACY ACT STATEMENT For Personal Information Taken During Inspector General Interviews.
AUTHORITY: Title 10 US Code, Sections 5014 and 5020.
PURPOSE: To determine the facts and circumstances surrounding allegations or complaints against Navy/Marine Corps
personnel
and/or activities. To present findings, conclusions and recommendations developed from investigations and other
inquiries to the Secretary of the Navy, CNO, CMC, or other appropriate commanders. Disclosure of Social Security Account
Number is voluntary, and if requested, is used to further identify the individual providing the information.
ROUTINE USES: The information is used for the purpose set forth above and may be:
a. Forwarded to federal, state or local law enforcement agencies for their use;
b. used as a basis for summaries, briefings or responses to Members of Congress or other agencies in the Executive
Branch of the Federal Government;
c. provided to Congress or other federal, state and local agencies, when determined necessary.
MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION:
a. For Military Personnel: Disclosure of personal information is mandatory and failure to do so may subject the individual
to disciplinary action.
b. For Department of the Navy Civilians: Failure to disclose personal information in relation to your position responsibilities
may subject the individual to adverse personnel action.
c. For All Other Personnel: Disclosure of personal information is voluntary and no adverse action can be taken against
individuals for refusing to provide information about themselves.
ACKNOWLEDGEMENT
I understand the provisions of the Privacy Act of 1974 as related to me through the foregoing statement.
Submit completed forms along with all supporting documents to:
Email: [email protected]
Fax: 202-781-4495
Mail: Naval Sea Systems Command (NAVSEA)
Office of the Inspector General
1333 Isaac Hull Avenue SE
Washington Navy Yard, DC 20376
5
CONTROLLED UNCLASSIFIED INFORMATION
When filled out, this document is subject to controls by NAVSEA IG. Prior to release, please contact NAVSEA IG for permission.
Signature
Date
THANK YOU FOR BRINGING THIS COMPLAINT TO OUR ATTENTION
Print
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OFFICE OF THE NAVSEA INSPECTOR GENERAL
FRAUD,
WASTE, ABUSE, & MISMANAGEMENT COMPLAINT FORM)
6
CONTROLLED UNCLASSIFIED INFORMATION
When filled out, this document is subject to controls by NAVSEA IG. Prior to release, please contact NAVSEA IG for permission.
SECTION VII – Additional Allegation Information Writing Area
This area is for you to provide additional information that would not fit within the boxes above:
