Contact Information* (optional)
Name	Date
Address
City/State/Zip Code	Telephone Number
Email Address	Alternate Telephone Number

*The University Ethics Office does accept anonymous ethics complaints; however, our inability to discuss this matter with you directly may prevent us from investigating this complaint.

If your complaint is referred to a different agency or office, do you want your name and contact information removed?* Yes No

* The University Ethics Office cannot guarantee that other entities can act on anonymous complaints.

Are you a State of Illinois Employee? Yes No

If yes, what agency are you employed with?

Details of Complaint
Date(s) the alleged violations occurred:
Is your complaint against an Illinois State University employee or vendor? Yes No* *If NO, our office lacks the authority to review or investigate your complaint and the complaint will be returned.
Have you notified any other Federal, State, or local agencies of your complaint or filed a lawsuit or grievance related to these matters? Yes No

Witness Information (if applicable)
Please provide the name, contact information, and any identifying information such as job title and/or department name for all witnesses. Attach additional sheets if necessary.
Witness #1 :
Witness #2 :
Witness #3 :
Subject(s) of Complaint
Please provide below the name, contact information (if available), and any identifying information such as job title and/or department name. Attach additional sheets as necessary.
Subject #1:
Subject #2:
Subject #3:

Description of Complaint
Please describe your complaint in detail. Additional sheets may be attached as necessary. Documentation in support of your complaint may also be attached.

I, the undersigned, do hereby authorize the University Ethics Office or other designated Illinois State University officials to conduct inquiries or investigation procedures as needed with respect to the investigation/resolution of this complaint. I understand the information regarding my complaint may be shared with applicable University officials in order to acquire sufficient information with respect to the investigation as well as any follow-up activities that may be required in relation to the University’s response to my complaint. I also authorize the University to use whatever information may be obtained with respect to this complaint in any legal or formal grievance proceedings that may involve the issues contained herein. I affirm that I have read the above complaint and that it is true to the best of my knowledge, information, and belief.
Signature	Date	University Ethics Officer	Date