DFS Employee Misconduct Form

YOUR CONTACT INFORMATION IS IMPORTANT TO US SO THAT WE CAN FULLY EVALUATE YOUR COMPLAINT. ONCE COMPLETED, THIS FORM WILL BE CONSIDERED PUBLIC RECORD UNLESS ONE OF A LIMITED NUMBER OF SPECIFIC EXEMPTIONS APPLY.

First Name

Last Name

Address:

City

State

Zipcode

Phone Number

PLEASE COMPLETE THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY.

Who are you reporting about?

Where are they employed with DFS?

Who else is aware of the activity/problem? (Please give complete names and contact information for each person.)

What specifically did this person do that may be a violation of law, rule, or department policy?

Please list the policy, law, rule, etc, which you believe has been violated.

When did this take place?

Where did this take place?

Have you or someone else reported this to another agency and/or manager and if so, when and to whom?

Any additional information you believe could assist?