VAOIG: Hotline - FAR Reporting Form

For information about this form please visit our FAR 52.203-13 Reporting Requirement information page.

Your Company Information (All mandatory fields are denoted with a *)

Your First Name*:
Your Last Name*:
Your Title*:
Your Business Email*:
Confirm Your Business Email*:
Company Name*:
Business Address1*:
Business Address2:
Business City*:
Business State / Province*:
Business Zip or Postal Code*:
Business Country*:
Business Phone Number*:
Business Fax Number:

Alternate Contact

First Name:
Last Name:
Title:
Business Email:
Business Phone Number:

Relationship (All mandatory fields are denoted with a *)

	*I am a principal officer or manager empowered to speak for the company
My company is the:

Contract Information

Contract No:
If applicable, the number(s) of all underlying task orders, blanket purchase agreements, purchase orders, or other related procurement documents relating to VA.
For each VA awarded contract, task order, purchase order, or blanket purchase agreement, identify the VA contracting officer or purchasing agent by name and facility.

Complete the following if the contract was awarded by another agency

Agency Name:
Contracting Officer:
Contracting Officer Phone Number:

Incident

Please include a detailed description of the facts and circumstances surrounding the reported activities, including the evidence forming the basis of this report, the names of the individuals involved, dates, location, how the matter was discovered, potential witness and their involvement, and any corrective action taken by the company.