USOE Report Fraud, Waste, or Abuse Form

HOTLINE COMPLAINT FORM

Complainant to remain anonymous?:

YesNo

Complainant would like a response?:

YesNo

Contact Information

Contact Type:

District/School EmployeeCitizen

Name:

Address, City, State, Zip:

Email:

District or School Name (if applicable):

Phone:

() -

Date:

Complaint Detail

Who is the person(s) the complaint is against? Who is the person’s supervisor? (Please provide name, position, district or school, and phone#. Also, supervisor’s name, position, and phone#. ):

Please describe your complaint or the activity you are reporting in detail. Include places, dates, times, and frequency of the event. Also, how do you know about the improper action? Did you see it occur?:

Are there any other persons who might provide information or who witnessed the event? If so, what are their names, positions, and their contact information? Has this activity been reported to anyone else?:

Is there evidence that can be examined or documentation that can be reviewed? (Please provide any documentation you have.) Did you see documentation indicating the event occurred?:

Do you know the source of funding involved or what specific law or state regulation has been violated?:

Supporting Documents

Supporting documentation file 1:

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Supporting documentation file 2:

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Supporting documentation file 3:

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Supporting documentation file 4:

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Supporting documentation file 5:

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Submit completed form

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Fax to: Natalie Grange (801) 538-7768

Mail to:

Utah State Office of Education

Internal Audit Section

Attn: Natalie Grange

250 East 500 South

PO Box 144200

Salt Lake City, Utah 84114-4200