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Your First Name
Your Last Name
Age
Sex
Male
Female
Street Address (Include Apt. #/Unit #, if applicable)
City
State
Zip Code
Home Phone
Business Number
Other Number
E-mail
Contact Preference
What is your preferred method of contact?
Employment
Are you employed by the State of Illinois, a State public university, CTA, Metra, PACE, or RTA?
Yes
No
Agency of Employment
If yes, which agency?
Job Title
Complaint Against Agency
Is your complaint against an employee(s), agency, or someone doing business with the State of Illinois, CTA, Metra, PACE, or RTA?
Yes
No
Agency
If yes, which agency?
Notified Others
Have you notified any other Federal, State or local agency of your complaint or filed a lawsuit or grievance related to these matters?
Yes
No
Agency Notified
If yes, with which agency did you file a complaint?
Agency Complaint Number
What is the complaint number?
Complaint Resolved
Has your complaint been resolved?
Yes
No
Resolution Summary
If yes, briefly summarize the results
Previous Complaint Filed
Have you previously filed a complaint with the OEIG?
Yes
No
OEIG Case Numbers
If yes, please list any known OEIG case numbers
Related Complaint
Is this complaint related to your previously filed OEIG complaint?
Yes
No
Reveal Name in Referral
If your complaint is referred, do you consent to the release of your identity as the complainant?
Yes
No
Reveal Name in Report
If the OEIG conducts an investigation and issues a report, do you consent to being identified as the complainant in that report?
Yes
No
Subject's First Name
Subject's Last Name
Subject's Phone
Subject's Age
Subject's Sex
Male
Female
Subject's Street Address
Subject's City
Subject's State
Subject's Zip
Subject's Agency
Subject's Job Title
Subject's Additional Information
2nd Subject's First Name
2nd Subject's Last Name
2nd Subject's Phone
2nd Subject's Age
2nd Subject's Sex
Male
Female
2nd Subject's Street Address
2nd Subject's City
2nd Subject's State
2nd Subject's Zip
2nd Subject's Agency
2nd Subject's Job Title
2nd Subject's Additional Information
3rd Subject's First Name
3rd Subject's Last Name
3rd Subject's Phone
3rd Subject's Age
3rd Subject's Sex
Male
Female
3rd Subject's Street Address
3rd Subject's City
3rd Subject's State
3rd Subject's Zip
3rd Subject's Agency
3rd Subject's Job Title
3rd Subject's Additional Information
4th Subject's First Name
4th Subject's Last Name
4th Subject's Phone
4th Subject's Age
4th Subject's Sex
Male
Female
4th Subject's Street Address
4th Subject's City
4th Subject's State
4th Subject's Zip
4th Subject's Agency
4th Subject's Job Title
4th Subject's Additional Information
Summary of Complaint
Required
Please summarize your complaint including date and time of alleged incident(s) (please attach any available documentation or other evidence in support of your complaint)
Witness First Name
Witness Last Name
Witness Agency
Witness Job Title
Witness Phone
Witness Additional Information
2nd Witness First Name
2nd Witness Last Name
2nd Witness Agency
2nd Witness Job Title
2nd Witness Phone
2nd Witness Additional Information
3rd Witness First Name
3rd Witness Last Name
3rd Witness Agency
3rd Witness Job Title
3rd Witness Phone
3rd Witness Additional Information
4th Witness First Name
4th Witness Last Name
4th Witness Agency
4th Witness Job Title
4th Witness Phone
4th Witness Additional Information
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Complaints
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Whistle Blower Protection