Fraud Assessment and Recoupment Form
Submit essential details to assess suspected fraud and document recoupment actions. Please complete all relevant sections below.
Case Reference ID
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Suspected Fraud
*
Internal
External
Systemic
Process Error
Other
Brief Description of Incident
*
Assessment of Fraud Likelihood
*
1
2
3
4
5
Estimated Recoupment Amount (USD)
*
Recoupment Status
*
Not Initiated
In Progress
Completed
Partially Recovered
Recoupment Actions Log
Rows
Action
Date
Status
Step 1
Pending
Completed
Failed
Step 2
Pending
Completed
Failed
Step 3
Pending
Completed
Failed
Responsible Assessor
*
Additional Notes
Submit
Should be Empty: