Contractor Reporting Form

Fields marked with * are required.

Your First Name:*   

Your Last Name:*   

Your Title:*   

Your Direct Work Phone Number:(xxx-xxx-xxxx)*  

Your Personal Phone Number:(xxx-xxx-xxxx)*  

Your Personal Email:*  

Your Company Email:*  

Company Address:*   

Company Address2:

Company City:*   

Company State:*   
-- Select One -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Company Zip:*  

Company Country:*   

Company Phone Number:(xxx-xxx-xxxx)*  

Company Fax Number:(xxx-xxx-xxxx)

My company is the Prime Contractor:*   
-- Select One -- No Yes Unknown

My company is the Sub Contractor:*   
-- Select One -- No Yes Unknown

I am reporting on my Company:*   
-- Select One -- No Yes Unknown

Name of Company I am Reporting On:*   

Affected Bureau within DOI:*   
-- Select One -- Bureau of Indian Affairs Bureau of Indian Education Bureau of Reclamation Bureau of Land Management Fish and Wildlife Service Mine and Minerals Service National Business Center National Park Service Office of Insular Affairs Office of the Secretary Office of Surface Mining Office of Special Trustee US Geological Survey Other

If other:   

DUNS or TINS:

EIN (if known):

Contract Number (if known):(xxx-xxx-xxxx)

Contracting Officer Name:

Contracting Officer Email:   

Dollar Amount of Loss:

Loss Description:*   

Was there an Overpayment:*   
-- Select One -- No Yes Unknown

Incident Date:*  
(mm/dd/yyyy)

Estimated Amount of Overpayment:

Was a Company Investigation Initiated?*   
-- Select One -- No Yes Unknown

Date Company Investigation Started:*  
(mm/dd/yyyy)

Name of Company Investigator:

Was a Company Investigation Completed?*   
-- Select One -- No Yes Unknown

Is Company willing to provide copy of report?*   
-- Select One -- No Yes Unknown

Measures taken to prevent recurrence:*   

Duration of Activity longer than 3 months:*   
-- Select One -- No Yes Unknown

Property Loss greater than $5000.00:*   
-- Select One -- No Yes Unknown

Monetary Loss greater than $5000.00:*   
-- Select One -- No Yes Unknown

Multiple Individuals involved (list names):

Actual/Potential Security Compromise:*   
-- Select One -- No Yes Unknown

Actual/Potential Public Safety threat:*   
-- Select One -- No Yes Unknown

Actual/Potential Misuse of Personal Information:*   
-- Select One -- No Yes Unknown

Counsel concurred with this reporting:*   
-- Select One -- No Yes Unknown

Comments: Please provide a complete description of the facts and circumstances surrounding the reported incident, 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. (maximum 1000 characters)

Your comments:*   

Please list any other entities you are notifying:

"I declare (certify/verify/state) under penalty of perjury (28 U.S.C. 1746) that this Contractor Disclosure Program submission is true and accurate to the best of my knowledge as of the date of its submission. (Must select Yes to submit). *  
-- Select One -- No Yes

"I understand and acknowledge that the submission of the foregoing Contractor Disclosure Program submission does not bar, prohibit, foreclose or preclude the Government from pursuing any and all criminal, civil, and/or administrative remedies provided to it by law and/or regulation against (a) the business entity(ies) making the forgoing Contractor Disclosure Program submission, (b) any other business entities mentioned in the submission and/or (c) any indivuduals mentioned in the submission. (Must select Yes to submit). *  
-- Select One -- No Yes

Certification: I certify that the information contained herein is true and correct to the best of my knowledge (Enter your name):*   

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