Fraud, Waste, or Abuse Report Form

See the following policies and procedures for more information:

• Internal Audit Brochure on Reporting Fraud, Waste, or Abuse
• ETSU Preventing and Reporting Fraud, Waste, or Abuse

The nature of your concern described below:* (Check all that apply)

Embezzlement, Theft, or Misuse of Funds or Assets

Mismanagement, Improper or Wasteful Activity

Environmental Violations

Forgery, False Statements/Certifications, or Alteration of Documents

Kickbacks, Bribes, or Extortion

Conflicts of Interest or Ethics Violations

Other (Please Describe Below)

Please provide a detailed description of the situation you wish to report:* 
Please indicate: who, what, when, where, why, and how.

What University Department(s) is/are involved?

What individuals are involved?

University Employee(s)

Student(s)

Other(s)

When did this occur - date or time period?

What is your relationship(s) if any with the individual(s) listed above?

How did you become aware of the problem being reported?

                 

Has this concern been reported to any other person or department?

No       

Yes                                                                                                                                                                     

If "Yes" then to whom and when?

Do you have any documents that would support the allegations?

If so, please attach them here:

Or, you can send them to Campus Box 70566, Johnson City, TN 37614

Are there any other individuals aware of this problem that could provide information or that you feel we should contact?

Name:

Contact Information:

Name:

Contact Information:

Name:

Contact Information:

Reporter's Information

Reports may be made anonymously. The identity or source of online reports is not tracked in any manner by Internal Audit.

(Not required for those who wish to remain anonymous)
 

Full Name

Work Address

Work Phone

Email