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FAR Contracting Reporting Form


This form is provided as a convenience to allow contractors to comply with the reporting requirements in the December 12, 2008, FAR amendment, 73 Fed. Reg. 67064. Specifically, contractors may use this form to satisfy the requirement that they notify, in writing, the agency USITC 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 an email will automatically be generated to send you a tracking number and a copy of what you have submitted. The information you are providing is not deemed to be submitted until you have received that confirmation email. If you wish to provide information that does not fall within these guidelines, please visit the Inspector General Hotline.

* indicates required fields

Your Company Information
First Name:
 
*
Last Name:  
*
Your Title:   *
Business Email:
 
*
Company Name:  
*
Business Address 1:   *
Business Address 2:  
Business City:   *
State:
 
*
Zip
  *
Business Country
  *
Business Phone Number:
  *
Fax Number:
 
Relationship
My company is the:
 
I am reporting on :
 
Contract Information
Contract No:
 
DUNS or TINS:
 
USITC Contracting Officer Name
 
Description of Services/Supplies/System:
 
Incident
Incident:
 
Estimated Amount of Loss
 
Loss Description
 
Incident Date:
  / /
Date Contractor learned of potential violation:
  / /
Attributes
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 seucrity 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 only the names, business email contact, and business phone for any individuals involved and/or potential witnesses.

Please list any other government entities you are notifying about this incident :
 
   
Validation
Please type the two words on the right in the field below them.
 
By selecting this box, I certify that this information is true.