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U.S. Department of Transportation | Calvin L. Scovel III, Inspector General

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FAR Contractor Reporting Form

Home / About Us / Hotline / FAR Contractor Reporting Form

Official Submitting Disclosure

First Name: *

Last Name: *

Title/Position: *

Email: *

Confirm Email: *

Company Name: *

Branch/Division: *

Address 1: *

Address 2:

City: *

State/Province: *

Zip/Postal Code: *

99999 or 99999-9999

Country: *

Telephone Number 1: *

999-999-9999

Telephone Number 2: *

999-999-9999

Fax Number: *

999-999-9999

Relationship

My Company is the: *

Prime

Sub

Other

If other, please specify:

I am reporting on: *

Prime

Sub

Other

Contractor Information

Contractor Name: *

Doing Business As (DBA): *

Dun & Bradstreet Number: *

Affected Corporate Branch / Division / Sector: *

Contractor's Address: *

(Number, Street Name, Suite Number, City, State, and Zip Code)

Contractor's Telephone Number: *

999-999-9999

Senior Corporate Point of Contact (POC): *

Senior Corporate POC Telephone Number: *

999-999-9999

Contract Information

Contract Number: *

Contract Type: *

Contract Name/Title: *

Contract Value: * $

$1,000,000.00

Description of Services / Supplies / System: *

Contract Performance Location: *

(Number, Street Name, Suite Number, City, State, and Zip Code)

Contracting Officer Name: *

Contracting Officer Address: *

(Number, Street Name, Suite Number, City, State, and Zip Code)

Contracting Officer Email: *

Contracting Officer Telephone Number: *

999-999-9999

Contracting Officer's Technical Representative (COTR): *

COTR Address: *

(Number, Street Name, Suite Number, City, State, and Zip Code)

COTR Telephone Number: *

999-999-9999

COTR Email: *

Incident

Initial Incident Date: *

Is the incident on-going?: *

Yes

No

Date Contractor learned of potential violation: *

Estimated Dollar Amount of Loss to the Government: * $

$1,000,000.00

Impact on which USDOT Operating Adminstration(s): *

FAA - Federal Aviation Administration

FHWA - Federal Highway Administration

FMCSA - Federal Motor Carrier Safety Administration

FRA - Federal Railroad Administration

FTA - Federal Transit Administration

NHTSA - National Highway Traffic Safety Administration

OST - Office of the Secretary of Transportation

PHMSA - Pipeline and Hazardous Materials Safety Administration

MARAD - Maritime Administration

RITA - Research and Innovative Technology Administration

SLSDC - Saint Lawrence Seaway Development Corporation

STB - Surface Transportation Board

Check all that apply.

Safety or Operational Hazards?: *

Yes

No

If yes, please describe:

The incident includes the following: *

Violation of Criminal Law

Violation of the Civil False Claims Act

Significant Overpayment

Check all that apply.

Measures taken or planned to mitigate safety or operational hazards: *

Are there other Federal Agencies affected by this incident?: *

Yes

No

If yes, which Agencies:

Have you reported this incident to any other Federal Agencies?: *

Yes

No

If yes, which Agencies?:

(Include contact information)

Has an investigation been conducted? (More than a Preliminary Inquiry): *

Yes

No

If yes, please describe the scope of the investigation:

(Employees interviewed, positions, records reviewed, etc.)

Is the company willing to provide a copy of the investigative report?: *

Yes

No

Measures taken or planned to prevent recurrence: *

Details

Provide a full description of the nature of the violation(s) being disclosed, including the period during which the violation(s) occurred, dates, locations, how the matter was discovered, potential witnesses, names of individuals involved, an explanation of their roles in the allegations and the relevant periods of their involvement, and any corrective action taken or planned by the company. Please be sure to provide the business email addresses and business phone numbers for all individuals and/or potential witnesses involved.

Description: *

Is the information being provided proprietary or otherwise exempt from public disclosure?: *

Yes

No

If yes, please explain:

Has supporting documentation been mailed to DOT/OIG under separate cover?: *

Yes

No

Acknowledgment

Affirm: *

I understand and acknowledge that the submission of the foregoing Contractor Disclosure Program submission does not bar, prohibit, foreclose or preclude the Government from pursuing any and all criminal, civil and/or administrative remedies provided to it by law and/or regulation against (a) the business entity(ies) making the forgoing Contractor Disclosure Program submission, (b) any other business entities mentioned in the submission and/or (c) any individuals mentioned in the submission.

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