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 submit classified information via the online complaint form. To submit a complaint involving classified information, please submit a complaint form with your contact information, and ONLY specify that your complaint involves classified information – no further details are necessary at this stage. Once your form is received, someone from our office will contact you to further assist in processing your hotline submission.

Fields with a red asterisk (*) are mandatory.

Your Information

Your Name

Your Title

Your E-mail Address

Your Phone (Home)

Your Phone (Work)

Your Phone (Mobile)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Your Employment Category

Employee of a contractor or sub-contractor

Employee of a grantee or sub-grantee

Personal Services Contractor

If none of these conditions apply to you please use the OIG Hotline Submission Form.

Employer

Employer Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Employer Phone

Disclosure Information

Who did you make a protected disclosure to?

Member of Congress or a representative of a Congressional committee

An Office of Inspector General

Government Accountability Office

Federal employee responsible for contract/grant oversight or management

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, sub-contractor, grantee or sub-grantee who has the responsibility to discover, investigate or address misconduct

When did you make this disclosure?

Please provide details of your disclosure including: who it was made to, their contact information, and how the disclosure was made

Reprisal Information

Please indicate the best category to describe the reprisal action

Discharged/Terminated

Demoted

Otherwise Discriminated Against

Check all the apply; must select at least one

Please provide details of the reprisal action including what happened, who did it, when it happened, and how

Previously Reported Reprisal

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

Federal judicial proceeding

Yes

Additional Details

If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes

Federal administrative proceeding

Yes

Additional Details

If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes

State judicial proceeding

Yes

Additional Details

If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes

State administrative proceeding

Yes

Additional Details

If yes, please provide the details of the proceedings including the jurisdiction, dates, location, and outcomes

Additional Details

Please include any other relevant details or other information, not otherwise reported in this form

If necessary, I authorize OIG an additional 180 days to investigate my complaint

Yes

Permission to contact

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.

Allegation Certification

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.