The following information is what your lawyers will need to
investigate your case. You may complete the form by typing
your answers below and clicking the print button. Then
simply mail your questionnaire to the address shown at the bottom of
this page. Please do not provide any confidential information
using the e-mail addresses on this site as your communication
will not be secure.
Confidential Questionnaire Form
For Potential Whistleblower
Part A. Personal Information about you
Name:
Street Address:
City:
State:
Zip:
Daytime Phone:
Nighttime Phone:
Other
Phone (Cell, Spouse):
Best
Time and Place to call:
Name
of Your Employer:
Address of Employer:
City:
State:
Zip:
Part B. False Claims Act Issues:
1. Does your case involve a Government contractor or
subcontractor?Yes:No:
2. Is the target defendant(s) in your case a nonprofit group,
individual, or a state agency? Yes:No:
3. What is the false claim that you know about?
4. How did you learn about the False Claims Act violations?
5. a. When did the False Claims Act violations begin to occur?
b. How
often did they occur?
c. Is the fraud still occurring?Yes:No:
6. a. Do you have any documents
or copies of them that help prove or describe the False Claims Act violations? Yes:No:
b.
What kinds of documents?
c. Where are the important documents to show the False
Claims Act violations located?
7. a. Are there other witnesses
to the fraud?Yes:No:
b. Do you think that they would be truthful is asked
about your claims by a government investigator or your
attorney? Yes:No:
8. a. Can you estimate how much money is involved in the scheme? b.
Can you estimate the
amount of money the government has paid as a result of the false
claims?
9. a. Have you complained to anyone employed by the company about
the fraud?Yes:No: b.
If so, who was it, when (the date), and what was said by you and
this other
person?
c.
Was the complaint written or oral?Written:Oral:
d. Was there any change
in the
company's practices after the complaint?
10. a. Did anyone employed by the defendant threaten or retaliate
against you?Yes:No:
b. Were
you terminated by the company?Yes:No:
c. Have you considered filing a
wrongful
termination lawsuit against the defendant?Yes:No:
11. a. Have you talked with or reported to anyone in the government
the potential False Claims Act violations? Yes:No:
b. Who did you talk to?
When? Do you have their full name, agency address, and phone number(s)?
c. Has the government told you anything about what they
might do with your information?
12. a. Have your allegations been the subject any media
reports?Yes:No:
b. What was the coverage?
13. a. What are your expectations for your lawyers?
b. What do you
hope to achieve as a result of legal representation or False
Claims Act litigation (i.e. set forth in your own words what you
expect, to obtain your job back, prevent future retaliation, or
a settlement of two years back pay, etc.)
Please send you completed questionnaire to:
Whistleblowerlaws.com
C/O
Ann Lugbill, Attorney at Law
2406 Auburn Ave.
Cincinnati, OH 45219
