Survey & Form Center

2. 
4. IMPORTANT
   To submit this form you do not have to sign or create a Form Center account above. However, you will have to complete the form in its entirety without the option to save your progress unless you do create an account.
6. Misuse of Funds / Misconduct Form

   This form was created so that the misuse of COMBAT funding by outside agencies and/or Jackson County Departments could be reported to the COMBAT administration. Other forms of alleged misconduct by COMBAT-funded agencies can also be reported using this form.

   If preferred, reports can be filed by calling 816-881-4337.

   REPORTS CAN BE SUBMITTED ANONYMOUSLY

8. WHO
10. County Department Or Agency*

    Are you reporting the misuse of funds or misconduct by a outside agency or Jackson County receiving COMBAT-funding?

    1. Outside Agency
    2. Jackson County Department
12. County Department*
    Identify the County Department involved in the alleged misuse of COMBAT funds.
14. Individuals Involved*
    List any individuals in the department directly involved in the alleged misuse of COMBAT funds.
16. COMBAT-Funded Agency*
    Identify the agencey involved in the alleged misuse of funds and/or miscondcut.
18. Individuals Involved*
    List any individuals directly involved in the alleged misuse of funds and/or misconduct.
20. WHAT
22. Describe Misconduct and/or Misuse of Funds:*
    Provide details of the alleged fraud, waste, misconduct, etc. Include any informatin you believe may be relevant.
24. Are you aware of any attempts to hide the misconduct?*

    1. Yes
    2. No
26. Please describe attempts to hide the misconduct:*
28. How and when was the misconduct discovered?*
30. How do you know about this allegation?*
32. Amount of money involved:
34. WHEN
36. When did misconduct or misuse of funds begin?*
38. Is the misconduct/misuse ongoing?*

    1. Yes
    2. No
    3. Not Sure
39. When did misconduct/misuse end?*
41. OTHER
43. Documents or Other Evidence
    List or describe any documents or other evidence you or others may have that is relevant to the alleged misconduct/misuse of funding.
45. Other Witnesses
    List names and contact information for other witnesses who can corroborate allegation and/or provide additonal information.
47. YOUR INFORMATION
49. Remain Anonymous

    1. I choose to remain anonymous

    I understand that this means COMBAT staff will not be able to contact me if additional information is needed from me, nor will I be able to request the status of the report I am submitting.
51. Remain Confidential

    1. I choose to remain confidential

    You may contact me for additonal information, but please keep my name confidential and do not share it outside the COMBAT or Jackson County Prosecutor's Office.
53. Confidentiality/Anonymity Waived

    1. I am NOT requesting confidentiality or anonymity

    You may contact me for additional information, and I do not place any restrictions on the use of my name.
55. Last Name
56. First Name
58. Address
60. City
61. State
62. Zip Code
64. email Address
65. Phone Number
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit Submit and Print

* indicates a required field