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Anonymous Whistleblower Disclosure Form

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Title

First Name

Last Name

Enter Email Confirm Email

Subject*

Section 1. Agency / Employment Information

With which agency is this complaint associated?*

If this complaint is associated with a specific office or department of the agency, please list it here:

How are you associated with the agency?*

If you are a current or former employee of the agency or contractor at issue, please provide your job title and classification if applicable. (e.g. competitive service, excepted service, or Senior Executive Service (SES))

Please provide a summary of your responsibilities in your current, or former, position.

If you are or were an employee of this agency, please specify your dates of employment:

If you are or were working with this agency through a contractor or subcontractor, please list the name of the contractor and/or subcontractor:

If you are or were working with this agency through a contractor or subcontractor, please specify your dates of employment:

If applicable, please list the specific contract or project that this complaint is associated with:

Section 2. Complaint Details

Summarize the observed waste, fraud, and/or abuse and specify when you learned about it. Please provide dates in chronological order. If your concerns involve a contract or a grant, please include the name of the contractor or grantee, type of contract or grant, dates of award, and contract numbers, if known.*

Have you reported or otherwise made a disclosure regarding this issue to an agency official, the Inspector General, a Congressional office or through other means?*

Yes

If yes, please specify to whom you made your disclosures. Please include dates in chronological order.

After making your disclosure, did you face any adverse personnel actions or retaliation?*

Yes

If yes, describe the adverse personnel actions or retaliation, including dates in chronological order. Please include the position of the employee who took the action and their relation to you. If you reported the retaliation, specify to whom you reported the retaliation to and any subsequent investigations or events.

Please note, Senate staff cannot act as your legal representation. Have you received or are you currently receiving legal assistance regarding this matter?

Yes

If so, please describe.

Are you currently involved in any legal or administrative proceedings or investigations related to your disclosure? (For example, are you currently involved in any investigations or proceedings with the following: the office of Inspector General for the named Agency, Office of Special Counsel (OSC), Merit Systems Protection Board (MSPB), Equal Employment Opportunity Commission (EEOC), etc.)

Yes

If so, please describe and include dates in chronological order and case numbers, if known.

What result or assistance are you seeking?*