NASA OIG Contractor Disclosure

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FAR Contractor Reporting Form

The purpose of this form is to allow the Contractor to notify, in writing, the agency Office of the Inspector General whenever the contractor has credible evidence that a principal, employee, agent, or subcontractor of the Contractor has committed a violation of the civil False Claims Act or a violation of Federal criminal law in connection with the award or performance of a contract or any related subcontract. The individual completing this form must be an officer or manager within the company for whom this report is being made and empowered to speak for the company by filing this report. If the information you wish to provide does not fall within these guidelines, please refer to the Inspector General Hotline/Fraud Reporting form.

Submitted reports will not be in effect until Dec 12th at 9:00am EST.

Alternatively you may report by writing to the following address:

NASA Office of Inspector General
PO Box 23089
L’Enfant Plaza Station
Washington, DC 20026

Your First Name:

Your Last Name:

Your Title:

Your Email:

Confirm Email:

Company Name:

Address 1:

Address 2:

City:

State/Province:

Zip/Postal Code:

Country:

Phone Number:

Fax Number:

Relationship:
My Company is the: (Prime or Sub)

Prime
Sub

I am reporting on: (Prime,Sub, Other)

Prime
Sub
Other

If other, please specify:

Contract Information:

Contract No:

Contract Officer Name:

Contract Officer Email:

Incident

Dollar Amount of Loss:

Loss Description:

Incident Date:

Which of the following best describes the reason for reporting this matter (check all that apply):

Possible violation of civil False Claims Act
Possible violation of Federal criminal law

Comments

Please provide a complete description of the facts and circumstances surrounding the reported incident, including names of individuals involved, dates, locations, how the matter was discovered, potential witnesses and their involvement, estimated monetary loss to the United States, and any corrective action taken by the company.

Certification

I certify that the information contained herein is true and correct to the best of my knowledge.

NAME:

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Curator: Michael Campbell
NASA Official: Lawrence Anderson
Last Updated: 12/03/2008
Last Reviewed: 12/03/2008