Anonymous Whistleblower Disclosure Form

Your Name


Your Message

Section 1. Agency/Employment Information





  1. (e.g. competitive service, excepted service, or Senior Executive Service (SES))






Section 2. Complaint Details


  1. 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.


  2. Yes
    No

  3. Yes
    No
    1. 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.


  4. Yes
    No

  5. (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
    No