ML13083A361
| ML13083A361 | |
| Person / Time | |
|---|---|
| Issue date: | 12/31/2012 |
| From: | NRC/OCIO/GEMSD/IMSB |
| To: | |
| References | |
| Download: ML13083A361 (3) | |
Text
U. S. NUCLEAR REGULATORY COMMISSION OFFICE OF THE INSPECTOR GENERAL FAR CONTRACTOR REPORTING FORM NRC FORM 835 (12-2012)
U.S. NUCLEAR REGULATORY COMMISSION Page 1 of 3 NRC FORM 835 (12-2012)
This form is to allow the contractor to notify, in writing, the agency (NRC) Office of the Inspector General, whenever the contractor has credible evidence that a principal, employee, agent, or subcontractor of the contractor has committed a violation of the Civil False Claims Act or a violation of Federal criminal law involving fraud, conflict of interest, bribery, or gratuity violations in connection with the award, performance, or closeout of a contract or any related subcontract. The individual completing this form must be an officer or manager empowered to speak for the company by filing this report.
Please print a copy of this form for your records before faxing or mailing. Mandatory fields are denoted with an asterisk (*).
If you wish to provide information that does not fall within these guidelines, please visit the OIG Hotline Web Site at www.nrc.gov/insp-gen/oighotline.html.
Instructions:
Your Disclosure Information:
Fill in, print, and sign the form.
Send by mail or facsimile to:
Your first name*
Your last name*
Your title*
U. S. Nuclear Regulatory Commission Office of the Inspector General Attention: FAR Contractor Reporting 11555 Rockville Pike - MS O-5E13 Rockville, MD 20852 Your business e-mail*
Confirm your business e-mail*
Your telephone number*
Fax - (301) 415-5091 Company Information Name of Company
- Company President or Director
- Affected Corporate Branch
- Doing Business As
- Business Address
- City, State, and Zip Code
- Country
- Telephone
- Fax Number
- Web Site
- U. S. NUCLEAR REGULATORY COMMISSION OFFICE OF THE INSPECTOR GENERAL FAR CONTRACTOR REPORTING FORM NRC FORM 835 (12-2012)
U.S. NUCLEAR REGULATORY COMMISSION Page 2 of 3 NRC FORM 835 (12-2012)
Contract Information DUNS Number NRC Contract Number NRC Contract Officer Short Title Description of Services/Supplies/Systems Contract Expiration Obligated Funds Type of Contract Contract Value Firm Fixed Price or Cost Reimbursable List of all Federal agencies with whom you or your company are conducting business Incident Description of Loss Estimated Amount of Loss Potential Violation Has an investigation been conducted?
Date Contractor Learned of Violation Yes No Attributes Duration of the activity longer than 3 months Does the incident you are reporting include any of the following attributes? (check all that apply)
Multiple individuals involved Actual or potential security compromise Actual or potential employee/public safety/health threat Actual or potential misuse of personally identifiable information Actual or potential national security threat Other (Explain in detail)
U. S. NUCLEAR REGULATORY COMMISSION OFFICE OF THE INSPECTOR GENERAL FAR CONTRACTOR REPORTING FORM NRC FORM 835 (12-2012)
U.S. NUCLEAR REGULATORY COMMISSION Page 3 of 3 NRC FORM 835 (12-2012)
Comments Please provide a complete description of the facts and circumstances surrounding the reported activities, 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.
Certification I certify that the information contained herein is true and correct to the best of my knowledge.
To access the Federal Acquisition Regulation click on these links:
NOTE: Please provide the names, email contact, and business phone for any individuals involved and/or potential witnesses.
Please list any other entities you are notifying:
Name:
Date:
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 foregoing Contractor Disclosure Program Submission, (b) any other business entities mentioned in the submission, and/or any individuals mentioned in the submission.
http://www.usda.gov/oig/webdocs/FARAmendment2008.pdf http://www.access.gpo.gov/su_docs/fedreg/frcont08.html