CPS 07 2022 Attachment 1 USDOL Incident Report Form DL 1 156

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U.S. Department of Labor Office of Inspector General seal

U.S. Department of Labor

Office of Inspector General

Incident Report

For Official Use Only (When filled in)

Report Tracking Information
1. Date of report 2. Agency designation code (Yr.) (Agency) (Report No.) 3. File Number (For IG use)

4. Type of report

  • Initial
  • Supplemental
  • Final
  • Other (Specify)

5. Type of incident

  • Conduct violation
  • Criminal violation
  • Program violation

6. Allegation against

  • DOL Employee
  • Contractor
  • Grantee
  • Other (Specify)

Given name and position of employee(s), contractor(s), grantee, etc. List telephone number, OWCP or other Claim File Numbber, if applicable, and other identifying data:

7. Location of incident (Give complete name(s) and addresses of organization(s) involved)

8. Date and time of incident/discovery

9. Source of complaint

  • Public
  • Contractor
  • Grantee
  • Program Participant
  • Audit
  • Invesstigative Law Enforcement Agency (Specify)
  • Other (Specify)

Give name and telephone number so additional information can be obtained.

10. Contacts with law enforcement agencies (Specify name(s) and agency contacted and results)

11. Expected concern to DOL

  • Local
  • Regional
  • National
  • Media interest
  • Executive interest
  • GAO/Congressional interest
  • Other (Specify)

12. DOL Agency involved

  • SECY
  • ESA
  • ETA
  • ILAB
  • LMSA
  • MSHA
  • OASAM
  • OIG
  • OSHA
  • SOL
  • ASP
  • BLS
  • NCEP
  • WB
  • OIPA
  • Other (Specify)
Amount of grant, contract, or subgrant
Amount of grant or contract (If known) $ Amount of subgrant of subcontract (If known) $
13. Persons who can provide additional information (Include custodian of records)
Name Grade Position or job title Employment¹ Local Address (Street, City, & State) or organization, if employed and telephone number

¹Enter one of these codes:

  • U - Unemployed
  • G-Grantee
  • C-Contractor
  • D - DOL
  • F-Other Federal Employee
  • P - Program Participant or claimant

(Complete page 2 of this form)

DL 1-156
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14. Details of Incident (Describe the Incident)

If more room is needed attach additional sheets.

15. Typed name and title of DOL employee

16. Signature of DOL employee

17. Copies furnished to:

18. Attachments: (List)

On