Contractor Whistleblower Reprisal Form

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‚Äč IG.

Contact Information
(home, work, cell)
Disclosure Information
Reprisal Information
Employment Information

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.