Note: Fields marked by * are required In order to fully investigate your whistleblower reprisal case, your name and contact information has to be made available to the appropriate investigating agency, which may be the Department of State IG or an IG office outside of the Department of State IG. Contact Information Name: * Address: * City, State and Zip: * E-mail Address: * Phone Number: * (home, work, cell) Disclosure Information Please indicate the categories that best represent the nature of your disclosure (mark all that apply): * Gross mismanagement of a Federal contract or grant Gross waste of Federal funds An abuse of authority relating to a Federal contract or grant A substantial and specific danger to public health or safety A violation of law, rule, or regulation related to a Federal contract (including the competition for, or negotiation of a contract) or grant Please describe in detail the nature of your disclosure, including when and where the event occurred, any witnesses to the event that can provide corroborating information, and any actions that were taken by the person(s) or agency to address the disclosure (not including the reprisal action). Please indicate the categories that best represent to whom you made your disclosure (mark all that apply): * A Member of Congress or a representative of a committee of Congress An Inspector General The Government Accountability Office A Federal employee responsible for contract or grant oversight or management at the relevant agency An authorized official of the Department of Justice or other law enforcement agency A court or grand jury A management official or other employee of the contractor, subcontractor, or grantee who has the responsibility to investigate, discover, or address misconduct Please provide details of to whom you made your disclosure, including how the disclosure was made (e.g. e-mail, letter by mail, verbally, etc.), the name and address of the person(s) or agencies to whom you made the disclosure, and the date the disclosure(s) was made. Reprisal Information Please indicate the categories that best represent the reprisal action (mark all that apply): * Discharged Demoted Otherwise discriminated against Please provide details of the reprisal action(s), including when and where the reprisal occurred; the name, position, and contact information of the individual and/or agency committing the reprisal; the presentation of the reprisal (i.e., verbally or in writing); and the delivery of the reprisal (e.g., in-person, via e-mail or mail, etc.) Please indicate whether you have addressed your reprisal to any of the following (mark all that apply): * Federal judicial proceeding Federal administrative proceeding State judicial proceeding State administrative proceeding None Please provide details of the judicial and/or administrative proceeding(s), including the jurisdictional body hearing the proceeding(s), the date and location of the proceeding(s), and the results of the proceeding(s). Employment Information Please indicate your employment status at the time of the reprisal (mark all that apply): * Employee of a contractor Employee of a sub-contractor Employee of a grantee Personal Services Contractor Please provide details of your employment, including the name, address, and contact information of your employer; the dates of your employment; your job title and a brief description of your duties; a description or number of the contract or grant involved (if known); the bureau/office that issued the contract/grant (if known); and the contact information for the contracting officer/grants officer administering the contract/grant (if known). By submitting this form, you certify that all of the statements made in this allegation (including continuation pages and addenda) are true, complete, and correct to the best of your knowledge and you understand that a deliberate false statement, or deliberate concealment of a material fact relating to the allegations herein is a criminal offense (Title 18 U.S.C. Section 1001) for which you may be prosecuted. Leave this field blank Submit
