OMBudsman Inquiry_Request Instrument

Ombudsman Inquiry/Request Form

Please use the form below to submit a question, report an issue you're having with regard to either your GSA contract or a GSA contracting opportunity.

OMB Control No: 3090-XXXX

Expires: XX/XX/XXX

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-XXXX. We estimate that it will take 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

*Required Field

Your Information

First Name*

Last Name*

Phone Number*

Email*

Company Name

DUNS Number

Size of Business

Small

Other

Your Inquiry / Issue / Suggestion*

Please describe the nature of your inquiry / issue.

Does your inquiry / issue relate to:

FAR 16.5 'Fair Opportunity'

General Procurement

If Reporting an Issue

Please specify which GSA Service/O韄�ice is involved:

FAS

PBS

TTS

Other

Please specify

Contract Status

Pre-Award

Solicitation ID

Post-Award

Award Number

Contracting Vehicle (e.g., GWAC, FSS, BPA, etc.)

GSA Contacts

Please provide the name(s) and contact information of individuals at GSA whom you have contacted to resolve this issue.

Confidentiality / Disclosure

Contacting the Ombudsman allows you to keep your identity and certain other information private. However, by requesting anonymity the Ombudsman may not have sufficient information to gather facts regarding your specific concern, possibly delaying or preventing potential resolution of the issue.

I request anonymity of my information:

Yes (if yes, results may be limited)

No

Privacy Act Notice

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized

by the Federal Property and Administrative Services Act of 1949, as amended, and Part III of Title 5, U.S.C; O. 9397

Disclosure of the information is voluntary. This form will be used as a means to prepare and issue a credential or pass.

Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or

regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in connection with the firing

or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a contract,

or the issuance of a license, grant, or other benefit. If the individual does not provide some or any part of the requested

information, the employee will not be issued a credential and will not be allowed to enter a GSA-controlled building after

normal working hours or when the building is under security.