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Agency Employee Fraud or Misconduct Questionnaire
Use this form to report agency employees misusing their positions.
You are on page 1 of 1. There are 12 questions to answer on this page.
Your personal information is optional, but would enable an investigator to contact you if additional information is needed. If you have been denied benefits or services due to employee misconduct, the Department may need to contact you in order to correct your situation. If you provide your name and telephone number, and wish to remain anonymous, your identity will not be disclosed unless legally required.
Your Telephone Number:
Would you prefer to remain anonymous?
Do you wish to be contacted by an investigator?
Please supply as much information as you can:
Program Area, if known:
Description of employee or employees (if names are not known):
Location of Offense:
If offense occurred during a telephone call, list telephone number called:
Date and Time of Offense:
Give a complete description of the offense or fraudulent activity that was or is being committed:
Department of Labor & Industry
Commonwealth of Pennsylvania. All Rights Reserved
DATE/TIME:Dec 12, 2013 2:01:29 PM