1. Identify The Employee Involved In The Wrongdoing? (Please provide as much information as possible)

First Name                                             Last Name

Job Title:                                                  SS #:

Place of Employment:

Work Address:                                Telephone: (ex., 555-555-5555)

Home Address:                               Telephone: (ex., 555-555-5555)

Email:

2. What is the complaint: (Please provide a detailed description of the wrongdoing)

3. Dates of Occurrence(s): (ex., MM/DD/YR)

4. IF YOU HAVE DOCUMENTATION SUPPORTING THIS COMPLAINT, PLEASE PROVIDE VIA FAX OR MAIL:

Department of Health & Mental Hygiene

Office of the Inspector General

201 W. Preston Street

Baltimore, Maryland 21201

FAX:  410/333-7194

5. Person Making This Complaint:  (optional)

Full Name: (Print)

Home Address: (Street Address, City, State, Zip Code)

Home Telephone: (ex., 555-555-5555)     Office Telephone: (ex., 555-555-5555)

DISCLAIMER: You may file this complaint anonymously.  However, despite efforts on behalf of the Office of the Inspector General to maintain your anonymity, you should know that your identity may eventually become known as a result of the investigation.