U.S. Department of Education: Promoting Educational Excellence for all Americans
OIG: Office of Inspector General

Contractor Business Ethics Compliance Program and Disclosure Form

Form is to allow the Contractor to notify, in writing, the agency (US Department of Education) 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 officer or manager empowered to speak for the company by filing this report. When you submit this electronic form an email will automatically be generated to send you a tracking number and a copy of what you have submitted so you may also forward it to the Contracting Officer. The information you are providing is not deemed to be submitted until you have received that confirmation email. This form is only for contractors reporting fraud in accordance with the Contractor Business Ethics Compliance Program and Disclosure Rule (12/12/08). If you wish to provide information that does not fall within these guidelines, please visit the Inspector General Hotline and submit the ED Inspector general's Hotline Special Complaint form (see link on this page).

Instructions
Fill in the form at below. If you are unsure if this form applies or you have any questions, please contact Counsel to the Inspector General at (202) 245-7011.

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

Your First Name*:
Your Last Name*:
Your Title*:
Your Business Email*:
Business Address1*:
Business Address2:
Business City*:
Business State / Province*:
Business Zip or Postal Code*:
Business Country*:
Business Phone Number*: (e.g., 555-555-5555)
Business Fax Number: (e.g., 555-555-5555)

Relationship:
My company is the:
I am reporting on:

Contract Information:
Contract No:
DUNS or TINS:
ED Contracting Officer Name:
ED Component / Region:
If other, please specify:
Description of Services/Supplies/System:

Incident:
Violation Description:
Incident Date:
Date contractor learned of potential violation:
Does this incident involve an overpayment? Yes: No:
If so, how much?
Has an investigation been conducted? Yes: No:

Does the incident you are reporting include any of the following attributes:
(check all that apply)
Duration of the activity longer than 3 months
Multiple individuals involved
Actual or potential security compromise
Actual or potential employee/public safety/health threat
Actual or potential misuse of personally identifiable information
Actual or potential national security threat

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 the names, email contact, and business phone for any individuals involved and/or potential witnesses.

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

Inspector General's Hotline
U.S. Department of Education
400 Maryland Avenue, SW
Washington, DC 20202-1500