TAQ Whistle-blower Form to Florida Commission on Human Relations

FCHR Whistle-blower Technical Assistance Questionnaire
1. Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
(or Country name if out of the states)
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
E-mail
Date of Birth*

MonthDayYear
Date
Gender Identity*

FemaleMaleNon-BinaryOther
2. Please provide the name of a person we can contact if we are unable to reach you
Contact Name*

First NameMiddle NameLast Name
Relationship*
Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
3. Discriminated by
I believe that I was discriminated against by the following (check those that apply):*

State AgencyIndependent Contractor on behalf of the stateOther
Organization Contact Information (If the organization is or was an employer, provide the address where you actually work or worked. If you work from home, check the box □ and provide the address of the office to which you report or reported.) If more than one employer is involved, fax or email additional sheets.

I work from Home
Organization Name
Address of the Organization

Street Address

Street Address Line 2

CityState

Zip Code
County
(or Country name if out of the states)
Organization's Phone Number

Area CodePhone Number
Type of Business
Job location if different from Organization's Address
Human Resources Director/Owner Name
HR/Owner phone number

Area CodePhone Number
4. Organization Representative
Organization Representative Contact Information (If known) - Representative Name:*
Representative address:

Street Address

Street Address Line 2

CityState

Zip Code
County
(or Country name if out of the states)
Representative phone number

Area CodePhone Number
Representative alternate Phone Number

Area CodePhone Number
Representative Email address
example@example.com
5. Your Employment Data (complete as many items as you are able)
Date hired*

MonthDayYear
Date
Job Title at hire
Job Title at time of alleged discrimination
Date of Harm / Quit / Discharged*

MonthDayYear
Date
Name and Title of immediate supervisor
6. What happened
What happened to you that you believe was retaliatory? Include the date(s) of harm, the action(s), and the name(s) and title(s) of the person(s) who you believe retaliated against you. Please fax or email additional pages if needed. (Example: 08/08/2011 – Discharged by Mr. John Smith, Supervisor) - Explain here*
7. Suspected act
What suspected act of gross mismanagement, malfeasance, misfeasance, gross waste or public funds, suspected or actual Medicaid fraud or abuse, or gross neglect of duty did you report? Include the date(s) of the report and the name(s) and title(s) of the person(s) who you reported to. Please fax or email additional pages if needed.
8. Have you filed a charge previously?
Have you filed a charge previously on this matter with the agency's Inspector General, the Chief Inspector General in the Governor's office, or any other agency?*

YesNo
If so, provide the name of the agency and the date of filing:
9. Attorney
Are you currently represented by an attorney?*

YesNo
If yes, please provide name, address, telephone number and email address

0/160
Mail or Fax to:

Florida Commission on Human Relations
4075 Esplanade Way, Room 110
Tallahassee, Florida 32399-7020
Telephone (850) 488-7082
Facsimile (850) 487-1007
Please, scroll up to review your information before you click "Submit", or to continue later, click "Save" button and you will get an email with the link to come back to this form.
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FCHR Whistle-blower Technical Assistance Questionnaire

1. Personal Information

2. Please provide the name of a person we can contact if we are unable to reach you

3. Discriminated by

4. Organization Representative

5. Your Employment Data (complete as many items as you are able)

6. What happened

7. Suspected act

8. Have you filed a charge previously?

9. Attorney