1

Would you like your identity to remain anonymous?

Would you like your identity to remain anonymous?

Yes

No

If no,

Would you like your identity to remain anonymous?

Would you like your identity to remain anonymous?

2

What is your preferred method of contact?

What is your preferred method of contact?

Email

Telephone

3

Are you an employee of Accomack County?

Are you an employee of Accomack County?

Yes

No

4

Please provide a description of the fraud, waste or abuse being reported.

Please provide a description of the fraud, waste or abuse being reported.

5

When did this act take place?  (Example: specific date, two weeks ago, last month)

When did this act take place? (Example: specific date, two weeks ago, last month)

6

What time did this act take place?

What time did this act take place?

7

If you have a picture or video of the incident, you can upload it below. Video formats allowed are: .mpeg and .mov

If you have a picture or video of the incident, you can upload it below. Video formats allowed are: .mpeg and .mov Click button for uploading file Clear Maximum size allowed: 25 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

8

Is management aware of this incident?

Is management aware of this incident?

Yes

No

Unsure

9

Please provide the name of the individual(s) who committed this act.  If you do not know the name of the individuals involved, please provide any information to help us identify the individual.

Please provide the name of the individual(s) who committed this act. If you do not know the name of the individuals involved, please provide any information to help us identify the individual.

10

How did you become aware of this incident?

How did you become aware of this incident?

I witnessed it

It was told to me by another person

It was told to me by an employee of Accomack County

I overheard it

I uncovered information about it

11

Please provide any other information that will help us investigate this matter.

Please provide any other information that will help us investigate this matter.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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