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House of Reps seal and a whistle

Template Whistleblower Online Intake Form

(SAMPLE FORM ONLY – NOT FOR SUBMISSIONS)

Legal Disclaimer: The information conveyed on this form is for general informational purposes only. Contents are not legal advice.

Whistleblowers play a vital role in helping Congress to conduct its constitutionally mandated oversight responsibilities. Your disclosures can make a difference.

The right to communicate with Congress is established in the First Amendment of the U.S. Constitution. Various U.S. laws prohibit retaliation for providing information to Congress, including 5 U.S. Code § 2302 (Prohibited Personnel Practices) for many Executive Branch employees, and numerous private-sector whistleblower protections. However, individuals still take serious risks when they make allegations of wrongdoing.

To better protect your communications, do not contact us using work resources or while you are working. Further, consider consulting an attorney experienced in representing whistleblowers before you make a disclosure. ;

If you wish to report misconduct, you may fill out the form below, contact us by telephone [INSERT], or email [INSERT].

Do not submit classified information or other information barred from release through this form or by email.

We respect your confidentiality, and we will use your contact information only to follow up with you regarding your submission. You may submit a disclosure anonymously. However, please be aware that anonymous disclosures may limit our ability to respond to the information that you provide.

Indicates required field
Identity
Are you willing to share your identity with us so that we may follow up with you?
Contact Information
Address:
Do you have a lawyer for this matter, and do you prefer we communicate through your lawyer?
Lawyer Contact Information
Employment
Your employment type
Complaint Details
Area(s) of Concern (select all that apply) [OPTIONAL TO INSERT BELOW ANY COMMON AREAS OF CONCERN FOR YOUR OFFICE/COMMITTEE JURISDICTION]
Please describe the issue(s) you want to disclose, including the alleged violator(s), the alleged wrongdoing, the location(s) and date(s) of the alleged wrongdoing. (3000 word count limit)
Have you filed your concerns elsewhere or contacted another government office about this allegation?
Do you believe you have experienced or been threatened with retaliation in connection with your concerns?
Additional Information
Are you a constituent?
Would you like to be contacted regarding this submission?