Contractor Employee, Grantee Employee, and Personal Services Contractor Whistleblower Reprisal Form

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Federal law protects individuals from retaliation (reprisal) for reporting potential misconduct or alleged criminal activities. The law prohibits retaliation against Federal contractor, subcontractor, grantee, subgrantee (Contractor/Grantee) employee and personnel services contractor whistleblowers.

For Federal Contractor/Grantee employees and personnel services contractors, it is illegal to be discharged, demoted, or otherwise discriminated against for making a protected whistleblower disclosure.

Also, under Presidential Policy Directive 19 (PPD-19), no action affecting access to classified information can be taken in reprisal for protected whistleblowing for Contractor/Grantee employees and personnel services contractors.

Complete this form if you are a Contractor/Grantee or if you are a personal services contractor of the Department of State, U.S. Agency for Global Media (USAGM), or the U.S. Section of the International Boundary and Water Commission (USIBWC) and reporting whistleblower reprisal.

For more information, visit www.stateoig.gov/whistleblower-protection

WARNING - Do not include any classified information. If reporting your complaint requires the disclosures of classified information DO NOT USE THIS FORM. Instead, please contact the OIG Hotline at 202-647-3320 or 800-409-9926 for proper reporting procedures. Do NOT discuss classified information over the phone.

Fields with a red asterisk (*) are mandatory.

Your Information
Your Address
Your Employment Category
If none of these conditions apply to you please use the OIG Hotline Submission Form.
Employer
Employer Address
Disclosure Information
Who did you make a protected disclosure to?
Reprisal Information
Please indicate the best category to describe the reprisal action
Check all the apply; must select at least one
Previously Reported Reprisal

Have you previously addressed this reprisal through any of the following?

Federal judicial proceeding
If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes
Federal administrative proceeding
If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes
State judicial proceeding
If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes
State administrative proceeding
If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes
Additional Details
If necessary, I authorize OIG an additional 180 days to investigate my complaint
In order to investigate this complaint, OIG must contact the agency involved and my employer. I acknowledge that I waive my confidentiality in this regard in order for OIG to investigate my complaint.
I certify that all of the statements made in this allegation (including continuation pages and addenda) are true, complete, and correct to the best my knowledge and I 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. § 1001) for what I may be prosecuted.