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FRAUD, WASTE & ABUSE COMPLAINTS
ON-LINE COMPLAINT FORM

Authority:	(a) Inspector General Act of 1978, as amended
	(b) DoD Directive 5106.01, "Inspector General of the Department of Defense", April 13, 2006
	(c) Department of Defense Directive 1401.3, “Reprisal Protection for Nonappropriated Fund Instrumentality Employees/Applicants,” October 16, 2001
	(d) DoD Instruction 7050.01, "Defense Hotline Program," December 17, 2007
	(e) DoD Directive 7050.06, "Military Whistleblower Protection," July 23, 2007

Prior to submitting your complaint to the Defense Hotline, we recommend you review the information located on the Defense Hotline Web pages at: www.dodig.mil/hotline (click-on) ABOUT THE HOTLINE and QUESTIONS AND ANSWERS. By using the enclosed on-line complaint form, you acknowledge that your privacy is not guaranteed because your complaint has not been encrypted. If you are not comfortable submitting your complaint via e-mail, you may mail your complaint to us at Defense Hotline, Pentagon, Washington, DC 20301-1900, or fax it to us at (703) 604-8567 (DSN: 664-8567). DoD civilian appropriated fund employees may also report their concerns to The Office of Special Counsel at http://www.osc.gov (click-on) FILE COMPLAINTS ONLINE. This on-line form is provided in accordance with the authority listed above.

Before forwarding your complaint, please read and acknowledge the certification below:

I certify that all of the statements made in this complaint (including continuation pages and addendums) are true, complete, and correct, to the best of my knowledge. I understand that a false statement or concealment of a material fact is a criminal offense (18 U.S.C. Section 1001).

Part I
Anonymity: Yes No
Confidentiality: Yes No
Interviewed: Yes No
1. Complaintant's Name:	Last Name:
	First Name:
	Middle Initial:
2. Status
Current DoD Civilian Position title Series and grade Former DoD Civilian Position title Series and grade
Contractor Employee
Military Active Duty National Guard Reserves
Other (Please specify below):
3. Contact Information:
Home or Mailing Address:	Street 1:
	Street 2:
	City:
	State:
	Zip Code:
Home Telephone: (Area Code & number)
Office Telephone: (Area Code & number)
Mobile Telephone: (Area Code & number)
E-Mail Address:
4. Agency , Command or Company Name:	Agency, Command or Company Name:
5. Agency, Command or Address:	Address 1:
	Address 2:
	City: State: Zip Code Country:

PART 2: DETAILS OF YOUR ALLEGATION
1. Potential Witnesses (Names of individuals that could provide additional supporting information):
Name	Organization




2. Please identify the organizational unit of the agency or command involved (include address if known:
3. Are you alleging reprisal? Yes (If yes, please go to Part 3.) No
4. Please describe the alleged wrongdoing. Be as specific as possible about dates, locations and the identities and positions of all persons named. Also, please attach any documents that support your complaint.

PART 3: Reprisal

A. What type of position did you hold when the alleged reprisal occurred?

1. Military Rank Army Navy Air Force Marine Corps

[NOTE for Military Service Members: Generally, no person may take (or threaten to take) an unfavorable personnel action, or withhold (or threaten to withhold) a favorable personnel action, as a reprisal against a member of the armed forces for making or preparing - a communication to a Member of Congress: an Inspector General; a member of a Department of Defense audit, inspection, investigation, or law enforcement organization; or any other person or organization (including any person or organization in the chain of command) designated pursuant to regulations or other established administrative procedures for such communications. ]

2. Contractor Employee

[NOTE for Contractor Employees: An employee of a contractor may not be discharged, demoted, or otherwise discriminated against as a reprisal for disclosing to a Member of Congress or an authorized official of an agency or the Department of Justice information relating to a substantial violation of law related to a contract (including the competition for or negotiation of a contract).]

3. Civilian Employee:

Appropriated Fund

[NOTE for Civilian Appropriated Fund Employees: Any employee who has authority to take, direct others to take, recommend, or approve any personnel action, shall not, with respect to such authority, take or threaten to take any action against any employee as a reprisal for making a complaint or disclosing information to the Special Counsel or to the Inspector General of an agency or another employee designated by the head of the agency to receive such disclosures of information which the employee, former employee, or applicant reasonably believes evidences - a violation of any law, rule, or regulation; or gross mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety.]

Non-Appropriated Fund (NAF)

[NOTE for Non-Appropriated Fund Civilian Employees: Any civilian employee or member of the armed forces who has authority to take, direct others to take, recommend, or approve any personnel action shall not, with respect to such authority, take or fail to take a personnel action with respect to any nonappropriated fund instrumentality employee (or any applicant for a position as such an employee) as a reprisal for - a disclosure of information by such an employee or applicant which the employee or applicant reasonably believes evidences – a violation of any law, rule, or regulation; or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety.]

B. Did you make or prepare to make a complaint that disclosed information regarding a violation of law or regulation, including sexual harassment or unlawful discrimination, mismanagement, a gross waste of funds or other resources, an abuse of authority, or a substantial and specific danger to public health or safety?

No
Yes (If yes, please answer question B.1.)

B.1. To whom did you make the disclosure(s) and when?

Date: Name:

Title: Rank or Grade:

Address:

C. What information did you disclose to that official? (Be as specific as possible.)

D. Was an unfavorable personnel action taken or threatened, or was a favorable action withheld or threatened to be withheld following your disclosure?

No
Yes

[NOTE – A personnel action is considered any action taken that affects or has the potential to affect your current position or career; e.g., a promotion; a disciplinary or other corrective action; a transfer or reassignment; a performance evaluation; a decision on pay, benefits, awards, or training; referral for mental health evaluations; and any other significant change in duties or responsibilities inconsistent with your rank.]

D.1 Describe the unfavorable personnel action.

D.2. When was/were the action (s) taken and who was/were the management official(s) responsible for taking the action?

Date: Name:

Title: Rank or Grade:

Address:

PART 4: OTHER ACTIONS YOU ARE TAKING ON YOUR DISCLOSURE

Did you disclose the information reported to the DoD Hotline through any other channel?
Yes
No

If yes, please identify the agency or command and provide the current status of the matter?

If you desire a copy of your complaint,
Select File, Print from your browser menu after you submit this form.

Thank you.