USAID Contractor Reporting Form

This form is provided as a convenience to allow contractors to comply with the reporting requirements in FAR Subpart 3.10, updated as of December 12, 2008 (Federal Acquisition Circular 2005-28, 73 FR 67090). Specifically, contractors may use this form to satisfy the requirement that they notify, in writing, the agency (USAID) 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 involving fraud, conflict of interest, bribery, or gratuity violations in connection with the award, performance, or closeout of a contract or any related subcontract. The individual completing this form must be an authorized representative empowered to speak for the company. When you submit this electronic form, you will receive confirmation that the form has been submitted, and OIG personnel will email you a tracking number so you may forward it to the Contracting Officer. If you wish to provide information that does not fall within these guidelines, please visit the Inspector General Hotline.

Instructions:

Fill in the form below. If you are unsure if this form applies or you have any questions, please contact Counsel to the Inspector General at (202) 712-1150.

USAID Office of Inspector General
1300 Pennsylvania Ave., NW
Washington, DC 20523

Your Company Information

Your First Name:

Your Last Name:

Your Title:

Your Business Email:

Confirm your Business Email:

Company Name:

Business Address 1:

Business Address 2:

Business City:

Business State:

Business Zip or Postal code:

Business Country:

Business Phone Number:

Business Fax Number:

Contract Officer Email:

Relationship

My Company is the:

I am Reporting on:

Contract No:

DUNS or TINS:

USAID Contracting Officer Name:

USAID Office :

Region:

If Other Office/Region - Please Specify:

Description of Services/Supplies/System:

Incident

Estimated Amount of Loss:

Loss Description:

Initial Incident Date:

Is the incident ongoing?:

Yes

Date contractor learned of potential violation:

Comments

Please provide a complete 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 witnesses and their involvement and any corrective action taken by the company.
NOTE: Please provide only the names, business email contact, and business phone for any individuals involved and/or potential witnesses. (Maximum No. of Characters: 2000)

Comments:

Please list any other government entities you are notifying about this incident:

Name:

USAID Contractor Reporting Form

Oversight