Contact Information
	How do you wish to be identified?	anonymous source confidential source no restriction
	If you chose to be identified as an anonymous source you do not need to supply additional contact information.
	Name:
	Email Address:
	Work Phone:
	Home Phone:
	Address:
	Are you a County Employee?	YesNo
	If yes, what department?
	Special instructions to contact you during business hours:
	Participants in Alleged Activity
	How many people are involved?
	Name:
	Department/Agency:
	Status:	county employee county contractor county vendor recipient of service other
	Allegation:	theft embezzlement bribe kickback conflict of interest misappropriation of resources unauthorized use of county equipment personnel improprieties payroll other
	Specifics
	Frequency:
	Date and times of incidents:
	Location/Address:
	Department:
	Description of allegation:
	Please describe how you became aware of the situation:
	Have you reported this allegation anywhere else?	YesNo
	If yes, to whom?
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	Email address: