prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.

Report 1: Beginning the summer 2013 through 2016, there were numerous reports in the media on sexual assault incidents in the U S  armed services  In many cases, such reports were followed by questions on what actions were taken by the Department of Defense (DOD), the Obama Administration, and Congress to address the issue  This report lists a comprehensive chronology of official activities in response to incidents of military sexual assault, as well as legislative action on the issue  The report is divided into three sections: the DOD and the Obama Administration's actions, congressional action, and legislation in the 113 th (2013-2014) and 114 th (2015-2016) Congresses  Also included is a resources section with related articles, hearings, and reports  Information in this report was compiled from the official government websites of DOD, the Obama White House and Congress gov for historical background and will not be updated  June 13, 2012 – DOD announced Army Major General Gary S  Patton as the new director of the Sexual Assault Prevention and Response Office (SAPRO)  September 25, 2012 – As part of the DOD's efforts to confront the crime of sexual assault in the military, then Secretary of Defense Leon Panetta announced improvements to prospective commander and senior enlisted training and a review of the initial military training environment in every service  December 21, 2012 – DOD released key findings from the Academic Program Year (APY) 2011-2012 Report on Sexual Harassment and Violence at the United States Military Service Academies  According to this report, the overall prevalence rate of unwanted sexual contact increased in all three military academies  From 2011 to 2012, the Air Force Academy in Colorado showed the largest increase in reported sexual assaults from 33 to 52 incidents  Sexual assaults at the Naval Academy in Annapolis, MD, increased from 11 to 15, and were up at the U S  Military Academy in West Point, NY, from 10 to 13  January 18, 2013 – DOD announced the release of the 2012 Workplace and Gender Relations Survey of Reserve Component Members   This report included rates of unwanted sexual contact, unwanted gender-related behaviors (i e , sexual harassment and sexist behavior), and gender discriminatory behaviors and sex discrimination reported by survey respondents during the past 12 months  March 7, 2013 – Defense Secretary Chuck Hagel, in a letter responding to Members of Congress, wrote that an internal review was being conducted of a decision by a senior Air Force commander, Lt  Gen  Craig Franklin, to overturn the sexual assault conviction of an Air Force fighter pilot, Lt  Col  James Wilkerson  Colonel Wilkerson was found guilty in November 2012 of aggravated sexual assault and was sentenced to one year in military prison  Lt  General Franklin's decision to overturn the findings of the court-martial freed Colonel Wilkerson, and allowed him to be reinstated in the Air Force  In his letter, Hagel said that while General Franklin's decision could not be overturned, he had asked Pentagon lawyers and the Secretary of the Air Force to review the way in which General Franklin decided the case  He also said he wanted a review of whether the military should change the way it handles sexual assault cases  April 2, 2013 – Secretary Chuck Hagel stated in a message to all DOD personnel on Sexual Assault Awareness and Prevention Month that, "Together, we must work every day to instill a climate that does not tolerate or ignore sexist behavior, sexual harassment, or sexual assault  These have no place in the United States military and violate everything we stand for and the values we defend " April 8, 2013 – Secretary Hagel announced that DOD's Office of General Counsel will review Article 60 of the Uniform Code of Military Justice (UCMJ) after an Air Force officer's court-martial conviction for sexual assault was dismissed using the authority provided by Article 60  May 6, 2013 – The Office of the Secretary of Defense released a 24-page memorandum from Secretary Hagel to all heads of the military services regarding DOD's 2013 Sexual Assault Prevention and Response Strategy, and the release of the Annual Report on Sexual Assault in the Military 2012 (2 volumes)  According to this report, in FY2012 (October 1, 2011, through September 30, 2012), the number of sexual assaults reported by members of the military rose 6% to 3,374  An anonymous survey of military personnel showed the number of service members who had experienced unwanted sexual contact could be as many as 26,000 but most never reported the incidents  That number is an increase over the 19,000 estimated assaults in 2011  These reports involved offenses ranging from abusive sexual contact to rape  May 7, 2013 – In a DOD press briefing, Defense Secretary Chuck Hagel and Major General Gary Patton, director of SAPRO, announced new series of actions to further DOD's sexual assault and prevention efforts  Hagel directed service chiefs to develop methods to hold all military commanders accountable for establishing command climates of dignity and respect in incorporating sexual assault prevention and victim care principles in their commands  May 7, 2013 – DOD announced the establishment of the Response Systems to Adult Sexual Assault Crimes Panel consisting of nine selected appointees  Secretary of Defense Hagel appointed five members to serve on the response systems panel, who joined four members appointed by the chairman and ranking member of the Senate Armed Services Committee, and the chairman and ranking member of the House Armed Services Committee  May 14, 2013 – The Army announced that an Army Sergeant First Class assigned to III Corps, Fort Hood, TX, was under investigation for pandering, abusive sexual contact, assault, and maltreatment of subordinates  May 15, 2013 – Returning from NATO meetings in Brussels, the Chairman of the Joint Chiefs of Staff, Army Gen  Martin E  Dempsey, told reporters that sexual assault in the Armed Forces constitutes a crisis in the military  He further stated that "We're losing the confidence of the women who serve that we can solve this problem, and that's a crisis " May 16, 2013 – At the White House, President Obama met with senior military leaders on the issue of sexual assault in the U S  Armed Forces  The President stated that not only is it "shameful and disgraceful" but also "dangerous to our national security " May 17, 2013 – During a press briefing, Defense Secretary Hagel and Chairman of the Joint Chiefs of Staff Army Gen  Martin Dempsey discussed their meeting with President Obama, Vice President Biden, and senior enlisted and officer leadership in the U S  military  Dempsey told the Armed Forces Press Service that he believes that the long wars in Iraq and Afghanistan may be factors in the growing incidents of sexual assault  He also stated that: "If a perpetrator shows up at a court-martial with a rack of ribbons and has four deployments and a Purple Heart, there is certainly a risk that we might be a little too forgiving of that particular crime " May 17, 2013 – In an interview, Air Force Chief of Staff, Gen  Mark Walsh, said that sexual assaults in his branch of the military typically involve alcohol use and can be traced to a lack of respect for women  "We have a problem with respect for women that leads to many of the situations that result in sexual assault in our Air Force," he told reporters in his Pentagon office  Walsh further stated that combatting the crisis is his top priority and that he reviews every reported case of sexual assault  May 22, 2013 – The Pentagon announced that DOD's sexual assault prevention staff would be exempt from furloughs  According to Pentagon spokeswoman, Cynthia O  Smith, "The full-time civilians working these programs and implementing policies will not be furloughed  This will ensure responsive victim care and ensure all the programs recently directed by Secretary Hagel are implemented swiftly and efficiently " May 24, 2013 – President Obama addressed graduates of the U S  Naval Academy in Annapolis, MD, and noted in his commencement speech that the misconduct of some in the military can endanger U S  forces and undermine U S  efforts to achieve security and peace worldwide  He further stated that those who commit sexual assault are not only committing a crime, they also "threaten the trust and discipline that make our military strong " May 25, 2013 – In a commencement speech at the U S  Military Academy at West Point, NY, Defense Secretary Chuck Hagel told graduates that they must be the generation of leaders that will commit to building a culture of respect for every member of the military  He stated that sexual harassment and sexual assault in the military "are a profound betrayal of sacred oaths and sacred trusts " He also quoted President Obama's remarks at the Naval Academy when he said, "these crimes have no place in the greatest military on earth " May 30, 2013 – Pentagon officials reaffirmed DOD's commitment to fighting sexual assault by launching the Safe HelpRoom at http://SafeHelpline org , a Sexual Assault Support Service for the DOD community  This new service allows victims to participate in moderated group chat sessions to connect with and support one another in a secure online environment  The Safe HelpRoom is in response to a need for peer support services identified by users of DOD's Safe Helpline for sexual assault victims  June 6, 2013 – In a speech at the 2013 Joint Women's Leadership Symposium, Navy Adm  James A  Winnefeld Jr , vice chairman of the Joint Chiefs of Staff, said plans to combat and eliminate sexual assault include a greater investment in specially trained sexual assault investigators and a push for more psychological, medical, and legal assistance for victims  The vice chairman also said officials will examine the scientific roots of behavioral factors associated with potential predators, which will assist sexual assault prevention efforts  June 7, 2013 – The Pentagon released a statement that Maj  Gen  Michael T  Harrison was suspended of his duties as the Commanding General of United States Army Japan and I Corps for failing in his duties as a commander to report or investigate an allegation of sexual assault  June 7, 2013 – Air Force officials announced Maj  Gen  Margaret H  Woodward has been assigned to direct the Air Force Sexual Assault Prevention and Response Office to replace Lt  Col  Jeffrey Krusinski, the former chief of the Air Force Sexual Assault Prevention and Response Program  He was arrested and charged by Arlington County, VA, police for allegedly being drunk and groping a woman in a parking lot one mile from the Pentagon  In the previous year, Maj  Gen  Woodward led the investigation of Air Force training in the wake of a sexual assault scandal centered at Lackland Air Force Base, Texas  June 27, 2013 – Defense Secretary Hagel met in person with the Sexual Assault Response Systems Review Panel for the first time  According to the Pentagon, "the panel will conduct an independent review and assessment of the systems used to investigate, prosecute, and adjudicate crimes involving sexual assault and related offenses under the Uniform Code of Military Justice, and will develop recommendations to improve the effectiveness of those systems " DOD established the panel in accordance with the National Defense Authorization Act (NDAA) for Fiscal Year 2013 ( P L  112-239 , Section 576 (a))  Previously, Hagel held a teleconference with panel members  July 3, 2013 – The Chief of the National Guard Bureau, Army Gen  Frank J  Grass, launched a comprehensive campaign designed to assist National Guard units in combating sexual assault as part of a military-wide effort to protect victims and eradicate the crime from the ranks  July 9, 2013 – DOD Inspector General (IG) released its report, Joint Warfighting and Readiness Evaluation of the Military Criminal Investigative Organizations Sexual Assault Investigations   The report evaluated the Military Criminal Investigative Organizations' (MCIOs') sexual assault investigations in 2010 to determine whether they were adequately investigated  The report found most MCIO investigations (89%) met or exceeded the investigative standards and returned only cases with significant deficiencies (11%) to the MCIOs for corrective action  July 18, 2013 – The Air Force adopted two new measures to eliminate sexual assault from within the ranks, including requiring mandatory discharge for airmen, officer or enlisted, who commit sexual assault, and requiring the Air Force's most senior commanders to review actions taken on these cases  In addition, the Air Force Academy is reviewing the results of a survey on sexual assault taken on June 24, 2013  Suggestions from survey respondents ranged from involving faculty with character coaching to a complete revamping of how the Air Force Academy trains its freshmen  July 18, 2013 – Secretary of the Navy Ray Mabus announced additional resources for investigators and a new initiative designed to enhance accountability and transparency across the Navy  Mabus approved nearly $10 million to hire more than 50 additional Naval Criminal Investigative Service (NCIS) Family and Sexual Violence Program personnel to shorten investigation times, and directed the Navy and Marine Corps to regularly publish online the results of each service's courts- martial  July 18, 2013 – The Air Force announced that airmen who commit sexual assaults will be discharged, and senior commanders must review actions taken on sexual assault cases under new Air Force initiatives as of July 2, 2013  August 15, 2013 – Defense Secretary Hagel announced seven new anti-sexual assault initiatives in a memo detailing "    absolute and sustained commitment to providing a safe environment in which every service member and DOD civilian is free from the threat of sexual harassment and assault," he wrote in a statement  "Our success depends on a dynamic and responsive approach  We, therefore, must continually assess and strive to improve our prevention and response programs " October 3, 2013 – Air Force Col  Alan R  Metzler, the deputy director for SAPRO, emphasized that the first step to stopping sexual assault in the military is through prevention but when prevention fails, new measures to improve victims' confidence and combat underreporting were needed  Metzler outlined the DOD Sexual Assault Advocate Certification Program (D-SAACP) and the Defense Sexual Assault Incident Database (DSAID), two initiatives set to improve the advocacy services provided to victims of sexual assault  November 9, 2013 – Army Maj  Gen  Gary S  Patton, director of DOD's SAPRO, reported on DOD's recent prevention and awareness successes before the Response Systems to Adult Sexual Assault Crimes Panel  He testified that new DOD initiatives to combat sexual assault helped create a 46% jump in victims reporting compared to the previous year  December 20, 2013 – President Obama instructed Defense Secretary Hagel and Chairman Dempsey to continue their efforts to make substantial improvements with respect to sexual assault prevention and response, including to the military justice system  He also directed that they report back with a full-scale review of their progress, by December 1, 2014  January 10, 2014 – Army Maj  Gen  Jeffrey J  Snow, the new SAPRO chief announced the release of the Annual Report to Congress on Sexual Harassment and Violence at the Military Service Academies   The report covered the 2012-13 academic year, and found in 2013, reports of sexual assault decreased at the U S  Military Academy at West Point, New York and the U S  Air Force Academy in Colorado Springs, Colorado  The number of reported incidents went up at the U S  Naval Academy in Annapolis, Maryland  January 30, 2014 – The independent Response Systems to Adult Sexual Assault Crimes Panel accepted a subcommittee recommendation that senior military commanders retain authority for referring these crimes to courts-martial  May 1, 2014 – DOD released the 2013 Annual Report on Sexual Assault in the Military   The report covered the period from Oct  1, 2012, through Sept  30, 2013, and revealed 5,061 reports of sexual assault in the Defense Department, a 50 percent jump from the previous year  More than 70 percent of all cases that the military had jurisdiction resulted in criminal charges  July 17, 2014 – DOD collaborated with the Justice Department's Office for Victims of Crime to develop a curriculum that expands on the skills learned in initial sexual assault response coordinator and sexual assault prevention and response victim advocate training  December 4, 2014 – Secretary Hagel released DOD's Report to the President of the United States on Sexual Assault Prevention and Response on its progress in addressing sexual assault in the military, and announced four directives to further strengthen the department's prevention and response program  According to this report, based on survey data, servicemembers experienced fewer sexual assaults in FY2014 than in FY2012, an estimated 19,000, down from 26,000  January 16, 2015 – Secretary Hagel at the Air Force Sexual Assault Prevention and Response Summit remarked that the fight to end sexual assault in the military must be "personal " He cited "encouraging progress" over the last year, but acknowledged more can be done, notably in areas such as social retaliation, which he said stems from the overall environment  February 11, 2015 – The annual report on sexual harassment and violence at the military service academies estimated that overall rates of unwanted sexual contact at the military service academies declined in Academic Program Year (APY) 2013-2014, decreased for both men and women, indicating that fewer sexual assaults occurred at the academies in APY 13-14 than in APY 11-12  February 19, 2015 – Health and criminal investigation experts spoke at the Army's Sexual Harassment/Assault Response Program Summit on the underreporting of male victims of sexual assault in the military due to factors such as shame and fear of being ostracized  March 26, 2015 – SAPRO head Army Maj  Gen  Jeffrey Snow monitored 50 initiatives put in place by past Defense secretaries Leon Panetta and Chuck Hagel  According to Snow, the most recent data, gathered last year, shows the past-year prevalence of sexual assault is down significantly, Snow said  Estimates indicate there were 6,000 to 7,000 fewer sexual assaults in 2014 than in 2012  May 1, 2015 – According to the 2014 RAND Military Workplace Stud y, "the percentage of active duty women who experienced unwanted sexual contact over the past year declined from 6 1% in 2012 to an estimated 4 3% in 2014  For active duty men, the estimated prevalence rate dropped from 1 2% in 2012 to 0 9% in 2014  Based on these rates, an estimated 18,900 service members experienced unwanted sexual contact in 2014, down from around 26,000 in 2012 " May 22, 2015 – Defense Secretary Ash Carter announced Army Maj  Gen  Camille M  Nichols will assume duties as director of SAPRO effective June 8, 2015  January 8, 2016 – DOD announced the release of the Annual Report on Sexual Harassment and Violence at the Military Service Academies for A cademic P rogram Y ear 2014-2015   Data in the report indicated the academies received 91 sexual assault reports during the academic year, an increase of 32 reports over the previous year  April 2 8 , 2016 – Defense Secretary Ash Carter announced a sexual assault retaliation prevention and response strategy aimed at how the department supports servicemembers who experience retaliation, while aligning prevention and response efforts across the services  May 5, 2016 – The annual report of the Defense Department's Sexual Assault Prevention and Response Program indicated that DOD's efforts are having an impact  In FY2015, service members made 6,083 reports of sexual assault – the same rate as the previous fiscal year, with four in 1,000 servicemembers reporting sexual assault despite a smaller active force size  In addition, 21 percent of those making restricted reports in fiscal 2015 chose to convert to unrestricted reports, enabling them to participate in the military justice process  September 19 , 2016 – The Naval Academy in Annapolis, MD, hosted an all-day training event to strengthen how military and civilian communities work together to support servicemembers who report sexual assault in a joint program between DOD and the Justice Department  October 19, 2016 – DOD released the 2016 Military Investigation and Justice Experience Survey that allowed servicemembers who have experienced sexual assault and elected to participate in the military justice process the opportunity to provide DOD with direct feedback on their experiences; and to improve the services and support servicemembers reporting sexual assault  December 15, 2016 – Defense Department officials announced the release of the "DOD Plan to Prevent and Respond to Sexual Assault of Military Men," designed to enhance outreach to military men and increase efforts to help them recover  The following information was compiled using Congress gov, Congressional Quarterly (CQ com), House gov, Senate gov, and Roll Call  See the section "Resources" for a list of congressional hearings, reports and other documents  January 23, 2013 – The House Armed Services Committee held a hearing on sexual misconduct at Lackland Air Force Base in San Antonio, TX  January 25, 2013 – H R  430 , Protect Our Military Trainees Act, was introduced  This legislation would have amended the Uniform Code of Military Justice to protect new members of the Armed Forces who are undergoing basic training from the sexual advances of the members of the Armed Forces responsible for their instruction  It also requires that violators be punished as a court-martial may direct  March 5, 2013 – H R  975 , the Servicemember Mental Health Review Act, was introduced  This bill would have amended Title 10, United States Code, to extend the duration of the Physical Disability Board of Review and to the expand the authority of such Board to review the separation of members of the Armed Forces on the basis of a mental condition not amounting to disability, including separation on the basis of a personality or adjustment disorder  This would have included a review of those victims who have suffered military sexual trauma  March 13, 2013 – S  548 , Military Sexual Assault Prevention Act of 2013, was introduced, read twice, and referred to the Senate Armed Services Committee  This legislation aimed to amend Title 10, United States Code, and to improve capabilities of the Armed Forces to prevent and respond to sexual assault and sexual harassment in the Armed Forces  March 13, 2013 – Victims of sexual assault in the military testified before a Senate panel examining the military's handling of sexual assault cases and stated that the "military justice system is broken " They urged Congress to make changes in the law that would stem the rape, sexual assault, and sexual harassment that they said are pervasive in the service branches  Several male Navy veterans testified before the Senate Armed Service Committee's military personnel panel investigating sexual assaults in the military  One recounted that he was raped in 2000 by a higher-ranking petty officer aboard a submarine  He told the committee that he carries permanent shame not for the sexual assault but over how the Navy forced him to leave  He stated in his testimony, "I carry my discharge as an official and permanent symbol of shame, on top of the trauma of the physical attack, the retaliation and its aftermath " March 20, 2013 – S  628 , Servicemember Mental Health Review Act, was introduced, read twice and referred to the Committee on Armed Services  Related to H R  975 , this bill would have amended Title 10, United States Code, to extend the duration of the Physical Disability Board of Review and to the expand the authority of such board to review the separation of members of the Armed Forces on the basis of a mental condition not amounting to disability, including separation on the basis of a personality or adjustment disorder  This would have included a review of those victims who may have suffered military sexual trauma  April 17, 2013 – H R  1593 , Sexual Assault Training Oversight and Prevention (STOP) Act, was introduced  This bill seeks to amend Title 10, United States Code, by establishing a Sexual Assault Oversight and Response Council and an enhanced Sexual Assault Oversight and Response Office "to improve the prevention of and response to sexual assault in the Armed Forces, and by requiring the appointment of a Director of Military Prosecutions for sexual-related offenses committed by a member of the Armed Forces " April 26, 2013 – A U S  senator reportedly put a hold on the nomination of Air Force Lt  Gen  Susan Helms, nominated to serve as vice commander of the U S  Space Command  Earlier in February 2012, Gen  Helms rejected the recommendation of legal counsel and overturned the conviction of an Air Force captain who had been found guilty of aggravated sexual assault of a female lieutenant  May 7, 2013 – S  871 , Combating Military Sexual Assault Act of 2013, was introduced, read twice and referred to the Committee on Armed Services  This legislation would have aimed to provide any victim with a special military lawyer who would assist them throughout the process, prohibit sexual contact between instructors and trainees during and within 30 days of completion of basic training or its equivalent, and ensure that sexual assault response coordinators are available to help members of the National Guard and Reserve  May 7, 2013 – H R  1864 , to amend Title 10, United States Code, would have required an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault, was introduced and referred to the House Armed Services Committee  This bill would have required the Inspector General of the Department of Defense (DOD), the Department of Homeland Security (DHS) with respect to the Coast Guard, or any of the military departments to investigate allegations of retaliatory personnel actions taken in response to making protected communications regarding alleged instances of rape, sexual assault, or other forms of sexual misconduct in violation of the Uniform Code of Military Justice  May 7, 2013 – At the Senate Armed Services Committee, Subcommittee on Personnel hearing Gen  Mark Welsh, the Air Force's Chief of Staff, told the committee that he and Air Force Secretary Michael Donley were "appalled" by the charges against Lt  Col  Jeffrey Krusinski, branch chief of the Air Force's Sexual Assault and Prevention Office  He was arrested and charged by Arlington County, VA, police for allegedly being drunk and groping a woman in a parking lot one mile from the Pentagon  "Sexual assault prevention and response efforts are critically important to us," Welsh said  "It is unacceptable that this occurs anywhere, at any time, in our Air Force " May 8, 2013 – H R  1867 , the Better Enforcement for Sexual Assault Free Environments (BE SAFE) Act of 2013, was introduced, read twice, and referred to the House Armed Services Committee  This bill would have amended Title 10, United States Code, "to require an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault " This bill would ensure those found guilty of rape, sexual assault, sodomy, or an attempt to commit any of those crimes, are—at a minimum—dismissed or dishonorably discharged from the military  The five-year statute of limitations within the military's justice system for sexual assault cases would be eliminated, and legal assistance services available to victims would be expanded  May 8, 2013 – In a hearing of the Defense Subcommittee of the Senate Appropriations Committee, senators questioned the Air Force's top leaders over rising sexual assaults in the military  Some senators cited DOD statistics from the Annual Report on Sexual Assault in the Military 2012 on the number of incidents of sexual assaults the same week Lt  Col  Jeffrey Krusinski, Chief of the Air Force's Sexual Assault Prevention and Response Branch, was arrested and charged with sexual battery  May 9, 2013 – A hearing of the Defense Subcommittee of the House Appropriations Committee on the Air Force budget was held  Witnesses included Michael Donley, Secretary of the Air Force, and General Mark Welsh, Air Force Chief of Staff  Members of the committee questioned them on Defense Secretary Hagel's review of the decision by Lt  Gen  Craig Franklin to dismiss Lt  Col  James Wilkerson's sexual assault conviction  May 14, 2013 – H Res  213 , a resolution to establish the "Special Committee on Sexual Assault and Abuse in the Armed Forces" was introduced  A "Dear Colleague" memorandum urged support of this legislation referencing Gen  Martin Dempsey's denouncement of military sexual assault as a "crisis" and the need for Congress to address this problem in a "deeper, more comprehensive manner " This Special Committee would have included 19 members appointed by the Speaker and Minority Leader, as well as chairman and ranking members of the committees on Armed Services, Appropriations, Judiciary, and Oversight and Government Reform  May 14, 2013 – H R  1960 , a bill to authorize appropriations for FY2014 for military activities of the Department of Defense, for military construction, and for defense activities of the Department of Energy, to prescribe military personnel strengths for such fiscal year, and for other purposes, was introduced  The FY2014 NDAA addressed the issue of sexual assault in the military by establishing minimum sentencing guidelines for any service members found guilty of sexual assault as well as other provisions  May 15, 2013 – H R  1986 , Sexual Assault Nurse Examiner (SANE) Deployment Act, was introduced  This bill would have provided for the assignment of Sexual Assault Nurse Examiners-Adult/Adolescent to brigades and equivalent units of the Armed Forces  May 15, 2013 – H R  2002 , Combating Military Sexual Assault Act of 2013, was introduced and referred to the House Committee on Armed Services  This bill was related to S  871 , and would have provided any sexual assault victim with a special military lawyer who would assist them throughout the process, prohibit sexual contact between instructors and trainees during and within 30 days of completion of basic training or its equivalent, and ensure that sexual assault response coordinators (SARCs) are available to help members of the National Guard and Reserve  May 16, 2013 – H R  2016 , Military Justice Improvement Act of 2013, was introduced and referred to the Committee on Armed Services  This bill would have required "a commanding officer who receives a report of a sexual-related offense involving a member in such officer's chain of command to act immediately upon such report by way of referral to the appropriate criminal investigative office or service " This bill was related to S  538 , Military Sexual Assault Prevention Act of 2013, and S  967 , Military Justice Improvement Act of 2013  May 16, 2013 – S  967 , Military Justice Improvement Act of 2013, was introduced, read twice, and referred to the Committee on Armed Services  This bill would have required a commanding officer who receives a report of a sex-related offense involving a member in such officer's chain of command to act immediately upon such report by way of referral to the appropriate criminal investigative office or service  May 21, 2013 – S  992 , a bill to provide for offices on sexual assault prevention and response under the Chiefs of Staff of the Armed Forces, to require reports on additional offices and selection of sexual assault prevention and response personnel, and for other purposes  This bill was read twice and referred to the Committee on Armed Services  May 22, 2013 – A House panel passed a number of changes in sexual assault prevention programs that limited commander discretion in reducing or dismissing rape and assault charges and expanded support services for victims  The House Armed Services Subcommittee on Military Personnel approved the personnel issues as part of H R  1960 , the FY2014 NDAA bill  May 22, 2013 – The Senate Appropriations Subcommittee on Defense held a hearing on the Army's FY 2014 Budget Request  Witnesses included Secretary of the Army, John McHugh and Chief of Staff of the Army, General Raymond T  Odierno  Army Secretary McHugh announced at this hearing that the service will soon require soldiers being considered for sexual assault prevention jobs to undergo behavioral-health evaluations as a way of screening out potential sex offenders from these high-profile positions  This was in response to a senator's question about the criteria for sexual assault prevention jobs  McHugh said that service record and availability are the only criteria commanders are using to fill these jobs since sexual-assault prevention positions do not fall under any military occupational specialty and lack career incentives  May 23, 2013 – S  1032 , Better Enforcement for Sexual Assault Free Environments Act of 2013, was introduced, read twice and referred to the Committee on Armed Services  This bill would amend Title 10, United States Code, to make certain improvements in the Uniform Code of Military Justice related to sex-related offenses committed by members of the Armed Forces  June 4, 2013 – The uniformed chiefs of the Army, Navy, Air Force, Marine Corps, and Coast Guard appeared before a hearing of the Senate Armed Services Committee, Subcommittee on Military Personnel  These military leaders acknowledged that despite a "zero tolerance" for sexual abuse, they had neglected the "epidemic" in the ranks by not always monitoring subordinate commanders  Chairman of the Joint Chiefs of Staff, Army Gen  Martin Dempsey pointed to competing demands and pressures of fighting two wars in Iraq and Afghanistan, as a justification for lack of adequate monitoring  The Service Chiefs voiced support for legislative changes that would take tougher action against offenders and provide more support for victims of military sexual assault  They opposed a legislative proposal that would remove unit commanders' legal power to oversee major criminal cases and transfer that authority to uniformed prosecutors  The Army Chief of Staff, Gen  Ray Odierno, noted that taking away commanders' authority in matters of military justice would adversely impact discipline and that "we cannot, however, simply 'prosecute' our way out of this problem  At its heart, sexual assault is a discipline issue that requires a culture change " June 4, 2013 – S  1092 was introduced, read twice, and referred to the Senate Armed Services Committee  This bill would have amended Title 10, United States Code, to require an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault  June 6, 2013 –would allow victims of sexual assault to apply for a permanent change The House Armed Services Committee passed H R  1960 , the NDAA for FY2014, by a vote of 59-2  According to the Committee's Fact Sheet, "the FY14 NDAA of station or unit transfer, while authorizing the Secretary of Defense to inform commanders of their authority to remove or temporarily reassign service members who are the alleged perpetrators of sexual assault  It also requires the provision of victims' counsels, qualified and specially trained lawyers in each of the services, to be made available to provide legal assistance to the victims of sex-related offenses  The FY14 NDAA adds rape, sexual assault, or other sexual misconduct to the protected communications of service members with a Member of Congress or an Inspector General " June 14, 2013 – The House passed H R  1960 , the NDAA for FY2014 by a vote of 315 to 108 (Roll no  244)  This bill includes a provision protecting victims of sexual assault in the Armed Forces as protected communications under military whistle-blower laws, to shield victims against retaliatory actions  The measure seeks to encourage more victims to report assaults, rape and other forms of sexual misconduct  June 17, 2013 – H R  2397 , "Department of Defense Appropriations Act, 2014," was introduced and referred to the House Committee on Appropriations  It was reported as an original measure, H Rept  113-113   Lawmakers wrote in this committee report that they were "outraged by the pervasive problem of sexual assault in the Armed Forces  Sexual assault is not just an issue in the military; it is an epidemic  To address it, the Committee believes that there must be a culture change at every level of the military, from the most senior leadership to the most junior ranks " Included was a measure that would provide $182 million for the Pentagon's Sexual Assault Prevention and Response Office (SAPRO) and for an expansion of a victim's counseling program  For FY2013, the programs received $95 million  The bill included $25 million that was not requested by the administration in a transfer account to expand assistance across the Defense Department  June 20, 2013 – S  1197 , NDAA for Fiscal Year 2014, was introduced in the Senate  This bill would have authorized "appropriations for fiscal year 2014 for military activities of the Department of Defense, for military construction, and for defense activities of the Department of Energy, to prescribe military personnel strengths for such fiscal year, and for other purposes," and referred to the Committee on Armed Services  The original measure was reported to the Senate in Report No  113-44 and placed on the Legislative Calendar under General Orders (Calendar No  91)  Included in this bill was Title V—Military Personnel Policy, Subtitle E—Sexual Assault Prevention and Response and Military Justice  June 27, 2013 – H R  1864 , a bill "To amend Title 10, United States Code, to require an Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault," was agreed to/passed in the House, 423-0 (Roll no  294)  July 18, 2013 – Army Gen  Martin E  Dempsey, the chairman of the Joint Chiefs of Staff, and Navy Adm  James A  Winnefeld Jr , the vice chairman, in a hearing before the Senate Armed Services Committee said that commanders should retain responsibility for prosecuting service members accused of sexual assault, and taking that authority away could harm good order and discipline  July 2 2 , 2013 – H R  2777 , Stop Pay for Violent Offenders Act, was introduced "to amend Title 10, United States Code, to authorize the Secretaries of the military departments to suspend the pay and allowances of a member of the Armed Forces who is held in confinement pending trial by court-martial or by civil authority for any sex-related offense or capital offense " July 24, 2013 – H Amdt  408 to H R  2397 , an amendment to provide funds to identify individuals who were separated from the military on the grounds of a disorder subsequent to reporting a sexual assault and, if appropriate, correcting their record  This amendment (A065) was agreed to by voice vote  July 24, 2013 – H R  2397 , "Department of Defense Appropriations Act, 2014," was passed/agreed to in House, 315 - 109 (Roll no  414)  October 22, 2013 – H R  3304 , the NDAA for FY2014, was introduced in the House  As introduced, the bill would have provided for a defense counsel interview of victim of an alleged sex-related offense in presence of trial counsel, counsel for the victim, or a Sexual Assault Victim Advocate, prohibition on service in the Armed Forces by individuals who have been convicted of certain sexual offenses, Coast Guard regulations regarding request for permanent change of station or unit transfer by victim of sexual assault, temporary administrative reassignment or removal of an active duty member accused of committing a sexual assault, Inspector General investigation of allegations of retaliatory personnel actions taken in response to making protected communications regarding sexual assault, compliance tracking of commanding officers in conducting organizational climate assessments for purposes of preventing and responding to sexual assaults, advancement of submittal deadline for report of independent panel on assessment of military response systems to sexual assault, retention of certain forms on sexual assault, timely access to Sexual Assault Response Coordinators by the National Guard and Reserves, and qualifications and selection of Department of Defense sexual assault prevention and response personnel and required availability of Sexual Assault Nurse Examiners  It also would establish commanding officer actions regarding sexual assault reports, an eight-day incident reporting requirement in response to unrestricted report of sexual assault in which the victim is a member of the Armed Forces, and curricula that addresses the prevention of sexual assault at the military service academies  December 26, 2013 – H R  3304 , the NDAA for FY2014 became P L  113-66   As enacted, the bill included more than two dozen provisions to address an epidemic of sexual assault in the military in Title XVII—Sexual Assault Prevention and Response and Related Reforms, Subtitle A—Reform of Uniform Code of Military Justice  February 26, 2014 – Dr  Karen S  Guice, principal deputy assistant secretary of defense for health affairs, and other Defense Department officials testified before the Senate Armed Services Committee's personnel subcommittee on the relationship between military sexual assault survivors and the subsequent development of suicide and post-traumatic stress disorder  April 9, 2014 – H R  4435 , the Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015, was introduced in the House  The bill would have applied Title XVII of the National Defense Authorization Act for Fiscal Year 2014 ( P L  113-66 ; 127 Stat  950) to the military service academies, consulted with victims of sexual assault regarding victims' preference for prosecution of offense by court-martial or civilian court, created a confidential review of characterization of terms of discharge for victims of sexual offenses, revised requirements relating to DOD policy on retention of evidence in a sexual assault case to allow return of personal property upon completion of related proceedings, required the DOD Inspector General to review separation of members who made unrestricted reports of sexual assault, and would have created a deadline for submission of report containing results of review of Office of Diversity Management and Equal Opportunity role in sexual harassment cases  Prior to passing in the House, the House Armed Services Committee rejected an amendment from Congresswoman Speier that would have removed the military chain of command from decisions to prosecute sexual assault cases and other major crimes, except offenses that are unique to the military  She offered an alternative proposal, which would have only removed commanding officers' prosecutorial discretion for instances of sexual assault, that was also rejected by a 28-34 vote  It was received in the Senate, read twice, and placed on Senate Legislative Calendar under General Orders  Calendar No  425  June 2, 2014 — S  2410 , the Carl Levin National Defense Authorization Act for Fiscal Year 2015, was introduced in the Senate  It was placed on Senate Legislative Calendar under General Orders  Calendar No  402  The bill included measures on military justice such as enhancing sexual assault prevention and response, the application of P L  113-66 , Title XVII to military academies, and the collaboration between the Departments of Justice and Defense  December 19 , 2014 — H R  3979 , the Carl Levin and Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015, was signed as P L  113-291   Subtitle D—Military Justice, Including Sexual Assault and Domestic Violence Prevention and Response addressed the following: modification of DOD policy on retention of evidence in a sexual assault cases to permit return of personal property upon completion of related proceedings; requirements relating to Sexual Assault Forensic Examiner; analysis and assessment of disposition of most serious offenses; a plan for limited use of certain information on sexual assaults in restricted reports by military criminal investigative organizations; the establishment of a Defense Advisory Committee on Investigation, Prosecution, and Defense of Sexual Assault in the Armed Forces; confidential review of the terms of discharge of sexual assault survivors; deadline for submission of report containing results of review of Office of Diversity Management and Equal Opportunity role in sexual harassment cases; and applied Title XVII of the NDAA for Fiscal Year 2014 ( P L  113-66 ; 127 Stat  950) to the military service academies  January 13, 2015 — S  178 , the Justice for Victims of Trafficking Act of 2015 was introduced in the Senate  Title V of this bill "Military Sex Offender Reporting" stipulates that the Secretary of Defense shall provide the Attorney General information about sex offenders in the military to be included in the National Sex Offender Registry and the Dru Sjodin National Sex Offender Public Website  It became P L  114-22 on May 29, 2015  February 3, 2015 — H R  677 , American Heroes COLA Act of 2015, was introduced in the House, passed on February 9, and the next day was received in the Senate, read twice, and referred to the Committee on Veterans' Affairs  Section 6 proposed that veterans whose claims were being reviewed again in relation to a previously denied claim relating to military sexual trauma be given priority, among other claims  February 12, 2015 — H R  956 , the Military Track, Register and Alert Communities Act of 2015 (Military TRAC Act) was introduced in the House and referred to the House Armed Services Committee's Subcommittee on Military Personnel on November 23  This bill intended to require DOD to maintain a sex offender registry of individuals convicted of certain sex offenses under the Uniform Code of Military Justice or of other military offenses appropriate for sex offender registration purposes  April 13, 2015 — H R  1735 , the National Defense Authorization Act for Fiscal Year 2016, was introduced in the House  Subtitle D addressed military justice, including sexual assault and domestic violence prevention and response  April 24, 2015 — H R  2029 , the Consolidated Appropriations Act, 2016 was introduced in the House and later became P L  114-113   Section 8057 specified that "$25,000,000 shall be for continued implementation and expansion of the Sexual Assault Special Victims' Counsel Program " May 14, 2015 — S  1356 , the National Defense Authorization Act for Fiscal Year 2016 was introduced in the Senate and later became P L  114-92 on November 25, 2015  Subtitle D "Military Justice, Including Sexual Assault and Domestic Violence Prevention and Response" amended the Uniform Code of Military Justice, authorized Special Victims' Counsel for civilian DOD employees, required the DOD to develop a policy to standardize the training for Special Victims' Counsel, required the establishment of Defense Advisory Committee on Investigation, Prosecution, and Defense of Sexual Assault in the Armed Forces within 90 days, required the development of a plan to improve prevention and response to sexual assaults of male members of the Armed Forces, required the establishment of a strategy to prevent retaliation against Armed Forces members who report or intervene on behalf of sexual assault victims, and authorized the President to modify Rule 304(c) of the Military Rules of Evidence to conform to the rules governing the admissibility of the corroboration of admissions and confessions in the trial of criminal cases in the U S  district courts  June 11, 2015 — S  1558 , Department of Defense Appropriations Act, 2016, was introduced in the Senate  The bill would have required specified O&M funds to be used for continued implementation and expansion of the Sexual Assault Prevention and Response Program  June 11, 2015 — S  1567 , a bill to amend Title 10, United States Code, to provide for a review of the characterization or terms of discharge from the Armed Forces of individuals with mental health disorders alleged to affect terms of discharge, was introduced in the Senate  The bill proposed to address medical evidence reviews for former members applying for relief from the terms of their discharge due to military sexual trauma among other conditions  June 11, 2015 — S Amdt  1578 to S Amdt  1463 in H R  1735 , National Defense Authorization Act for Fiscal Year 2016, was proposed in the Senate and later considered and defeated on June 16  This bill was intended to reform procedures for determinations to proceed to trial by court-martial for certain offenses under the Uniform Code of Military Justice  It did not achieve 60 votes in the Senate by Yea-Nay Vote  The final vote was 50 - 49  April 12, 2016 — H R  4909 , the NDAA for FY2017, was introduced in the House where it passed on May 18  On May 26, it was received in the Senate, read twice, and placed on Senate Legislative Calendar under General Orders  Calendar No  502  April 18, 2016 — H R  4991 , the Prevent Retaliation and Open up Transparency to Expand Care for Troops (PROTECT) Act of 2016, was introduced in the House and later referred to the House Armed Services' Subcommittee on Military Personnel  The bill intended to amend the Uniform Code of Military Justice to establish the offense of retaliation with provisions that would permit any person intent on retaliating against anyone for reporting or planning to report a criminal offense to be punished as a court-martial may direct  May 18, 2016 — S  2943 , the National Defense Authorization Act for Fiscal Year 2017, was introduced in the Senate and became P L  114-328 on December 23  Subtitle D specified requirements for the review by a discharge review board of claims by former members asserting post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in connection with combat or sexual trauma  Subtitle E "Military Justice and Legal Assistance Matters" required an annual report on sexual assault and response efforts, required Sexual Assault Prevention and Response Office to establish evaluation metrics and best practices in the prevention of and response to retaliation, and modified the definition of sexual harassment for the purposes of investigations of complaints of harassment by commanding officers  Title XXXV "Maritime Matters" established requirements for policies and training regarding sexual harassment and sexual assault prevention and response at the U S  Merchant Marine Academy and required the Inspector General of the Department of Transportation to submit a report to Congress about the sexual harassment and sexual assault prevention and response program at the U S  Merchant Marine Academy  Title LIV "Court-Martial Jurisdiction" specified the sexual offenses over which general courts-martial have exclusive jurisdiction  Title LX "Punitive Articles" created a new section of the Uniform Code of Military Justice addressing accountability for sexual misconduct committed by recruiters and trainers during the various phases within the recruiting and basic military training environments, revised the definition of ''sexual act'' with respect to the offenses of rape and sexual assault  May 19, 2016 — H R  5293 , Department of Defense Appropriations Act, 2017, was introduced in the House, passed on June 16, received in the Senate the next day, where it received a motion to proceed to consideration  The bill would have required O&M funds to be used for continued implementation and expansion of the Sexual Assault Prevention and Response (SAPR) Program  May 26, 2016 — S  3000 , Department of Defense Appropriations Act, 2017, was introduced in the Senate and placed on Senate Legislative Calendar under General Orders  Calendar No  500  The Senate Committee on Appropriations, Subcommittee on Department of Defense held several hearings prior from February-April  The bill would have required specified O&M funds to be used for continued implementation and expansion of the SAPR Program  DOD Directive No  6495 01  "Sexual Assault Prevention and Response (SAPR) Program," January 23, 2012, Incorporating Change 3, April 11, 2017, at http://www esd whs mil/Portals/54/Documents/DD/issuances/dodd/649501p pdf DOD Directive No  6495 02  "Sexual Assault Prevention and Response (SAPR) Program Procedures," March 28, 2013, Incorporating Change 3, May 24, 2017, at https://www esd whs mil/Portals/54/Documents/DD/issuances/dodi/649502p pdf DOD Inspector General (IG)  E valuation of the Military Criminal Investigative Organizations Sexual Assault Investigations, DODIG-2013-091, July 9, 2013, 104 p   at http://www dodig mil/reports html/Article/1118941/evaluation-of-the-military-criminal-investigative-organizations-sexual-assault/ Sexual Assault Prevention and Response Office (SAPRO) at https://www sapr mil/ Includes the full text of DOD Annual Reports, FY2004 - FY2016, and reports on Sexual Harassment and Violence at the U S  Military Service Academies, Academic Program Years (APY) 2005-2018  "Final 2014–2015 Academic Program Year Annual Report on Sexual Harassment and Sexual Assault at the United States Merchant Marine Academy," Maritime Administration, undetermined date, at https://www marad dot gov/wp-content/uploads/pdf/Final-2014-2015-SASH-Report pdf "Department of Transportation U S  Merchant Marine Academy Culture Audit, Deliverable 4  Final Report," U S  Merchant Marine Academy, December 2016, at https://cms dot gov/sites/dot gov/files/docs/mission/civil-rights/263966/dot-usmma-report pdf "Sexual Assault Prevention and Response (SAPR) Program," United States Coast Guard, LMI, December 2016, at https://media defense gov/2017/Mar/29/2001723560/-1/-1/0/CIM_1754_10E PDF "Preliminary 2015-2016 Academic Year Biennial Survey and Report on Sexual Harassment and Sexual Assault at the United States Merchant Marine Academy," Maritime Administration, January 12, 2017, at https://www marad dot gov/wp-content/uploads/pdf/Preliminary-2015-2016-SASH-Report pdf Military Justice: Oversight and Better Collaboration Needed for Sexual Assault Investigations and Adjudications , GAO-11-579, Jun 22, 2011, 42 p  http://www gao gov/products/GAO-11-579 Preventing Sexual Harassment: DOD Needs Greater Leadership Commitment and an Oversight Framework , GAO-11-809, Sep 21, 2011, 47 p  http://www gao gov/assets/590/585344 pdf Prior GAO Work on DOD's Actions to Prevent and Respond to Sexual Assault in the Military , GAO-12-571R, Mar 30, 2012, 40 p  http://www gao gov/assets/590/589780 pdf DOD Has Taken Steps to Meet the Health Needs of Deployed Servicewomen, but Actions Are Needed to Enhance Care for Sexual Assault Victims, GAO-13-182, January 29, 2013, 40 p  http://www gao gov/assets/660/651624 pdf Military Personnel: Actions Needed to Address Sexual Assaults of Male Servicemembers, Report to the Committee on Armed Services , GAO-15-284, March 19, 2015, 86 p  http://www gao gov/products/GAO-15-284 Sexual Assault: Actions Needed to Improve DOD's Prevention Strategy and to Help Ensure It Is Effectively Implemented, GAO-16-61, November 4, 2015, 59 p  http://www gao gov/products/GAO-16-61 DOD and Coast Guard: Actions Needed to Increase Oversight and Management Information on Hazing Incidents Involving Servicemembers, GAO-16-226, Feb 9, 2016, 74 p  http://www gao gov/products/GAO-16-226 The following news sources are listed in chronological order to make it easier to follow the numerous incidents of wide-spread misconduct reported in the media  Military com has ongoing news on military sexual assault at http://www military com/topics/sexual-assault   Montgomery, Nancy  "Johnson Found Guilty of Last Two Counts; Awaits Sentencing " Stars and Stripes , June 13, 2012, at http://www stripes com/news/johnson-found-guilty-of-last-two-counts-awaits-sentencing-1 180204 Carroll, Chris  "Air Force has Identified 31 Alleged Victims in Lackland Sex Abuse Scandal," Stars and Stripes, June 28, 2012, at http://www stripes com/news/air-force-has-identified-31-alleged-victims-in-lackland-sex-abuse-scandal-1 181597 Dao, James  "Instructor for Air Force Is Convicted in Sex Assaults," New York Times , July 20, 2012, at http://www nytimes com/2012/07/21/us/lackland-air-force-base-instructor-guilty-of-sex-assaults html?pagewanted=all&_r=0 Blansett, Susan and Hoffman, Michael  "Sexual Assault Cases Flood Military Courts," Military com, August 13, 2012, at http://www military com/daily-news/2012/08/13/sex-assault-cases-flood-military-courts html Risen, James  "Honor Betrayed: Attacked at 19 by an Air Force Trainer, and Speaking Out," New York Times , February 26, 2013, at http://www nytimes com/2013/02/27/us/former-air-force-recruit-speaks-out-about-rape-by-her-sergeant-at-lackland html?pagewanted=all Mulrine, Anne  "Seeking the Sex-Assault Solution," Air Force Magazine , April 2013, at http://www airforcemag com/MagazineArchive/Pages/2013/April%202013/0413solution aspx "5 Former Lackland Commanders Disciplined," Military com, May 2, 2013, at http://www military com/daily-news/2013/05/02/5-former-lackland-commanders-disciplined html Kime, Patricia  "Lawmakers Act Fast with New Legislation on Military Sexual Assault " Army Times , May 7, 2013  Shapira, Ian  "July Trial Set for Jeffrey Krusinski, Air Force Officer Accused of Sexual Battery " Washington Post , May 9, 2013, at https://www washingtonpost com/local/july-trial-set-for-air-force-officer-accused-of-sexual-battery/2013/05/09/8a21eb92-b8d9-11e2-92f3-f291801936b8_story html?utm_term= e0d4951e6573 Steinhauer, Jennifer  "Lawmakers, at White House, Discuss Sex Abuse in Military " New York Times , May 9, 2013, at http://www nytimes com/2013/05/10/us/politics/lawmakers-huddle-at-white-house-on-sex-abuse-in-military html?_r=0 Whitlock, Craig  "Pentagon Grapples with Sex Crimes by Military Recruiters," Washington Post , May 12, 2013, at http://articles washingtonpost com/2013-05-12/world/39210853_1_military-recruiters-sexual-abuse-army-reserve Sisk, Richard  "Assault Prevention NCO Investigated for Sex Crimes " Military com, May 15, 2013, at http://www military com/daily-news/2013/05/15/assault-prevention-nco-investigated-for-sex-crimes html Whitlock, Craig  "Some in Congress want Changes in Military Law as a Result of Sex Crimes," Washington Post , May 15, 2013, at http://www washingtonpost com/world/national-security/some-in-congress-want-changes-in-military-law-as-result-of-sex-crimes/2013/05/15/672a2a8a-bd8b-11e2-a31d-a41b2414d001_story html Sisk, Richard  "Sex Assault Crisis Pushes Senate to Overhaul UCMJ," Military com, May 16, 2013, at http://www military com/daily-news/2013/05/16/sex-assault-crisis-pushes-senate-to-overhaul-ucmj html Tilghman, Andrew  "Dempsey: DOD May Have Become 'Too Forgiving' of Sexual Assault," Army Times , May 17, 2013  Brady, Gen  Roger Brady (ret )  "Commentary: Telling Truths about Sexual Assault is Risky," Air Force Times , May  21, 2013  Salcedo, Michele  "Senator: Fire Commanders Allowing Sex Assault," Army Times, May 26, 2013  Tucker, Eric  "More Details Released on Annapolis Sex Assault Investigation: Allegations Made Against Three Football Players," Navy Times , May 30, 2013  Lardner, Richard  "Brass Seeks to Temper Military Justice Overhaul," Associated Press, June 3, 2013, at http://www military com/daily-news/2013/06/03/brass-seeks-to-temper-military-justice-overhaul html Cassata, Donna and Richard Lardner  "Sexual Assaults Force Changes to Military Justice," Associated Press, June 4, 2013, at http://www military com/daily-news/2013/06/04/sexual-assaults-force-changes-to-military-justice html Zengerle, Patricia  "U S  Lawmakers Act to Limit Military Authority in Sex Assault Cases," Reuters, June 5, 2013, at http://www reuters com/article/2013/06/05/us-usa-military-sexassault-congress-idUSBRE9541IG20130605 Cassata, Donna and Richard Lardner  " House OKs 2-Yr Jail Term for Military Sex Assault ," Associated Press, June 14, 2013, at http://www military com/daily-news/2013/06/14/house-oks-2-year-jail-term-for-military-sex-assault html Montgomery, Nancy  " After 2 decades of sexual assault in military, no real change in message ," Stars and Stripes , July 7, 2013, at https://www stripes com/news/after-2-decades-of-sexual-assault-in-military-no-real-change-in-message-1 229091 Steinhauer, Jennifer  "Complex Fight in Senate over Curbing Military Sex Assaults," New York Times , June 14, 2013, at http://www nytimes com/2013/06/15/us/politics/in-senate-complex-fight-over-curbing-sexual-military-assaults html?pagewanted=all Dao, James  "In Debate over Military Sexual Assault, Men Are Overlooked Victims," New York Times , June 23, 2013, at http://www nytimes com/2013/06/24/us/in-debate-over-military-sexual-assault-men-are-overlooked-victims html?pagewanted=all&_r=0 Sisk, Richard  "Military Tries to Sever Booze, Sex Assault Link," Military com, July 8, 2013, at http://www military com/daily-news/2013/07/08/military-tries-to-sever-booze-sex-assault-link html Watson, Julie  "Military Works to Change Culture to Combat Rape," Associated Press, July 15, 2013, at http://www military com/daily-news/2013/07/15/military-works-to-change-culture-to-combat-rape html Olson, Wyatt  "IG Review Finds Deficiencies in Sex Assault Cases," Stars and Stripes, July 16, 2013, at http://www military com/daily-news/2013/07/16/ig-review-finds-deficiencies-in-sex-assault-cases html Shanker, Thom  "New Support for Military in Sex Cases," New York Times , July 24, 2013, at http://www nytimes com/2013/07/25/us/politics/new-support-for-military-in-sex-cases html Taranto, James  "A Strange Sort of Justice at West Point," The Wall Street Journal, July 26, 2013, at https://www wsj com/articles/a-strange-sort-of-justice-at-west-point-1376453937 Cassata, Donna, "Senator Targets Military Law over Sexual Assault," Associated Press, July 29, 2013, at http://www military com/daily-news/2013/07/29/senator-targets-military-law-over-sexual-assault html?comp=7000023317843&rank=3 Groer, Annie  " Military brass claim progress in pursuing sexual assault cases ," Washington Post, August 1, 2013, at https://www washingtonpost com/blogs/she-the-people/wp/2013/08/01/military-brass-claim-progress-in-pursing-sexual-assault-cases/?utm_term= 72e55e7e218c Jennifer Koons  "Sexual Assault in the Military: Can the Pentagon stem the rise in incidents?" CQ Researcher , vol  23, no  29 (A ugust 9, 2013 ), p p  693-716   Laird, Lorelei  " Military lawyers confront changes as sexual assault becomes big news ," ABA (American Bar Association) Journal , September 2013, at http://www abajournal com/magazine/article/military_lawyers_confront_changes_as_sexual_assault_becomes_big_news/ Jelinek, Pauline  " Pentagon: Reports of Sexual Assault Up 46 Percent ," Associated Press, November 8, 2013, at http://www military com/daily-news/2013/11/08/pentagon-reports-of-sexual-assault-up-46-percent html Matthews, Michael F  " The Untold Story of Military Sexual Assault ," The New York Times, November 24, 2013, at http://www nytimes com/2013/11/25/opinion/the-untold-story-of-military-sexual-assault html " Men Sexually Assaulted in the Military Speak Out ," Baltimore Sun, December 20, 2013, at http://www military com/daily-news/2013/12/20/men-sexually-assaulted-in-the-military-speak-out html Kageyama, Yuri and Richard Lardner  "Documents Reveal Chaotic Military Sex-Abuse Record," Associated Press, February 10, 2014, at http://www military com/daily-news/2014/02/10/documents-reveal-chaotic-military-sex-abuse-record html Montgomery, Nancy  "AF Program Rare Bright Spot in Sex Assault Fight," Stars and Stripes , February 27, 2014, at http://www military com/daily-news/2014/02/27/air-force-program-rare-bright-spot-in-sex-assault-fight html Cox, Matthew  "Alcohol Policies Reviewed as Sex Assault Rises," Military com, May 1, 2014, at http://www military com/daily-news/2014/05/01/alcohol-policies-reviewed-as-sex-assault-rises html Burns, Robert  "Army Knocks 2-Star Down to 1-Star Rank," Associated Press, August 27, 2014, at http://www military com/daily-news/2014/08/27/army-knocks-2-star-down-to-1-star-rank html Milham, Matt  "Army: It's Good News That Sexual Assault Reports Are Up," Stars and Stripes , September 26, 2014, at http://www military com/daily-news/2014/09/26/army-its-good-news-that-sexual-assault-reports-are-up html Draper, Robert  The Military's Rough Justice on Sexual Assault," New York Times , November 26, 2014, at https://www nytimes com/2014/11/30/magazine/the-militarys-rough-justice-on-sexual-assault html Sisk, Richard  "Sexual Assault Reports Increase 8%, Pentagon Cites Progress," Military com, December 4, 2014, at http://www military com/daily-news/2014/12/04/sexual-assault-reports-increase-8-pentagon-cites-progress html Baldor, Lolita C  "Male Military Sex Assault Victims Slow to Complain," Associated Press, December 9, 2014, at http://www military com/daily-news/2014/12/09/male-military-sex-assault-victims-slow-to-complain html Roulo, Claudette  "Sexual Assault Rates Decrease at Military Service Academies," DOD News, Defense Media Activity, February 11, 2015, at http://archive defense gov/news/newsarticle aspx?id=128158 Pellerin, Cheryl  "DOD Honors Sexual Assault Response Coordinators," DOD News, April 23, 2015, at https://www defense gov/News/Article/Article/604510/ Rowe, Major Derek  "General courts-martial for sexual assault: How do they work?" Air Force News , April 28, 2015, at http://www af mil/News/Commentaries/Display/Article/586763/general-courts-martial-for-sexual-assault-how-do-they-work/ Sisk, Richard  "Military Sexual Assault Reports Increased 11 Percent Last Year," Military com, May 1, 2015, at http://www military com/daily-news/2015/05/01/military-sexual-assault-reports-increased-11-percent-last-year html Johnson, Lieutenant General Michelle D , U S  Air Force Academy superintendent; Vice Admiral Walter E  "Ted" Carter Jr , superintendent, U S  Naval Academy; Lieutenant General Robert L  Caslen, superintendent, U S  Military Academy; Rear Admiral James A  Helis, superintendent, U S  Merchant Marine Academy; Rear Admiral Sandra L  Stosz, superintendent, U S  Coast Guard Academy  "Lessons to Share: The five superintendents of federal service academies discuss how their institutions -- which faced scrutiny over sexual assault before many other colleges attracted such attention -- have responded to the issue," Inside Higher Ed, May 7, 2015, at https://www insidehighered com/views/2015/05/07/essay-how-federal-service-academics-prevent-and-punish-sexual-assault Tilghman, Andrew  "Military sexual assault claims: 1 in 20 lead to jail time," Military Times, May 13, 2015, at https://www militarytimes com/2015/05/13/military-sexual-assault-claims-1-in-20-lead-to-jail-time/ Schogol, Jeff  "Defense seeks dismissal of sexual assault case transferred to Washington," Air Force Times, October 17, 2015, at https://www airforcetimes com/news/your-air-force/2015/10/17/defense-seeks-dismissal-of-sexual-assault-case-transferred-to-washington/ Whitlock, Craig  "In the war against sexual assault, the Army keeps shooting itself in the foot," Washington Post, December 19, 2015, at https://www washingtonpost com/news/checkpoint/wp/2015/12/19/in-the-war-against-sexual-assault-the-army-keeps-shooting-itself-in-the-foot/?utm_term= d856136e939b Defense Media Activity  "Defense Department Proposes UCMJ Changes," DOD News, December 28, 2015, at https://www defense gov/News/Article/Article/638108/defense-department-proposes-ucmj-changes/ Losey, Stephen  "USAF launches new strategy to curb sexual assault," Air Force Times, December 30, 2015, at https://www airforcetimes com/news/your-air-force/2015/12/30/usaf-launches-new-strategy-to-curb-sexual-assault/ Kime, Patricia  "Sexual assault reporting rises at U S  service academies," Military Times , January 8, 2016, at https://www militarytimes com/news/your-military/2016/01/08/sexual-assault-reporting-rises-at-u-s-service-academies/ Larter, David B  "Navy sex assault victims may be eligible for early separation," Navy Times, January 20, 2016, at https://www navytimes com/news/your-navy/2016/01/20/navy-sex-assault-victims-may-be-eligible-for-early-separation/ Cox, John Woodrow  "Why sex assault reports have spiked at the Naval Academy, West Point and the Air Force Academy, Washington Post , March 11, 2016, at https://www washingtonpost com/news/checkpoint/wp/2016/03/11/why-sex-assault-reports-have-spiked-at-the-naval-academy-west-point-and-the-air-force-academy/?utm_term= a5e15f2f16f1 Whitlock, Craig, Thomas Gibbons-Neff  "Military bringing more charges against ofﬁcers for sexual assault," Washington Post, March 20, 2016, at https://www stripes com/news/us/military-bringing-more-charges-against-of%EF%AC%81cers-for-sexual-assault-1 400140# WeTFNOFRXUc Lardner, Richard  "Pentagon misled lawmakers on military sexual assault cases," Associated Press , April 18, 2016, at https://apnews com/23aed8a571f64a9d9c81271f0c6ae2fa/pentagon-misled-lawmakers-military-sexual-assault-cases Kheel, Rebecca  "Senators ask Obama to investigate whether Pentagon misled Congress," The Hill, April 19, 2016, at http://thehill com/policy/defense/276832-senators-ask-obama-to-investigate-pentagons-sexual-assault-comments Secretary of the Air Force Public Affairs  "Air Force report on sexual assault highlights program's progress," Air Force News , May 05, 2016, at http://www af mil/News/Article-Display/Article/752653/air-force-report-on-sexual-assault-highlights-programs-progress/ Tilghman, Andrew  "Military sex assault: Just 4 percent of complaints result in convictions," Military Times , May 5, 2016, at https://www militarytimes com/veterans/2016/05/05/military-sex-assault-just-4-percent-of-complaints-result-in-convictions/ Montgomery, Nancy  "US Military Court Addresses 'Incapable of Consent' to Sex Issue," Stars and Stripes , May 18, 2016, at http://www military com/daily-news/2016/05/18/us-military-court-addresses-incapable-of-consent-to-sex-issue html Losey, Stephen  "Military must do right by wrongly-discharged sexual assault victims, advocates say," Air Force Times , May 19, 2016, at https://www airforcetimes com/news/your-air-force/2016/05/19/military-must-do-right-by-wrongly-discharged-sexual-assault-victims-advocates-say/ Lyle, Amaani  "DoD Safe Helpline Offers Specialized Support to Sexual Assault Victims," DOD News, July 15, 2016, at https://dod defense gov/News/Article/Article/841166/dod-safe-helpline-offers-specialized-support-to-sexual-assault-victims/ Rein, Lisa  "Merchant Marine Academy under fire for sexual assault allegations," Stars and Stripes, August 12, 2016, at https://www stripes com/news/us/merchant-marine-academy-under-fire-for-sexual-assault-allegations-1 423595 Lyle, Amaani  "DoD Unveils Plan to Broaden Sexual Assault Support to Men," DOD News, Defense Media Activity, December 15, 2016, at https://www defense gov/News/Article/Article/1030795/dod-unveils-plan-to-broaden-sexual-assault-support-to-men/ The following sources are listed in alphabetical order by author  Burgess, Ann W , Donna M  Slattery, and Patricia A  Herlihy  "Military Sexual Trauma: A Silent Syndrome " Journal of Psychosocial Nursing & Mental Health Services 51, no  2 (2013): 20-6  D'Ambrosio-Woodward, Tricia  "Military Sexual Assault: A Comparative Legal Analysis of the 2012 Department of Defense Report on Sexual Assault in the Military: What It Tells Us, What It Doesn't Tell Us, and How Inconsistent Statistic Gathering Inhibits Winning the 'Invisible War '" Wisconsin Journal of Law, Gender & Society 29, no  2 (2014): 173-211  Farris, Coreen, Terry L  Schell and Terri Tanielian  Physical and Psychological Health Following Military Sexual Assault: Recommendations for Care, Research, and Policy   Santa Monica, CA: RAND Corporation, 2013  http://www rand org/pubs/occasional_papers/OP382 Firestone, Juanita M , J  M  Miller, and Richard Harris  "Implications for Criminal Justice from the 2002 and 2006 Department of Defense Gender Relations and Sexual Harassment Surveys " American Journal of Criminal Justice : AJCJ 37, no  3 (2012): 432-451  Gibson, Carolyn J , Kristen E  Gray, Jodie G  Katon, Tracy L  Simpson, and Keren Lehavot  "Sexual Assault, Sexual Harassment, and Physical Victimization during Military Service across Age Cohorts of Women Veterans " Women's Health Issues 26, no  2 (2016): 225-231  Harrell, Margaret C , Laura Werber, Marisa Adelson, Sarah J  Gaillot, Charlotte Lynch and Amanda Pomeroy  A Compendium of Sexual Assault Research   Santa Monica, CA: RAND Corporation, 2009  http://www rand org/pubs/technical_reports/TR617 Holland, Kathryn, Rabelo, Verónica, and Cortina, Lilia  Sexual Assault Training in the Military: Evaluating Efforts to End the 'Invisible War ' American Journal of Community Psychology 54, no  3/4 (2014): 289-303  Morral, Andrew R , Kristie Gore, and Terry L  Schell  Sexual Assault and Sexual Harassment in the U S  Military, Volume 1  Design of the 2014 RAND Military Workplace Study   Santa Monica, CA: RAND Corporation, National Defense Research Institute, 2014  https://www rand org/pubs/research_briefs/RB9841 html Morral, Andrew R , Kristie Gore, and Terry L  Schell  Sexual Assault and Sexual Harassment in the U S  military: Volume 2  Estimates for Department of Defense Service members from the 2014 RAND Military Workplace Study   Santa Monica, CA: RAND Corporation, National Defense Research Institute, 2015  https://www rand org/pubs/research_reports/RR870z2-1 html O'Brien, Carol, Jessica Keith, and Lisa Shoemaker  "Don't Tell: Military Culture and Male Rape " Psychological Services 12, no  4 (2015): 357-365  Stander, Valeria A  and Cynthia J  Thomsen  "Sexual Harassment and Assault in the U S  Military: A Review of Policy and Research Trends " AMSUS Military Medicine (Association of Military Surgeons of the United States) 181, no  1S (2016): 20-27  This chronological list of hearings was compiled from Congress gov and CQ com  U S  Congress, House Armed Services Committee, A Review of Sexual Misconduct by Basic Training Instructors at Lackland Air Force Base , 113 th Cong , 1 st sess , January 23, 2013, H A S C  No  113-2 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for 2014 , Part 1, 113th Cong , 1 st sess , February 26, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, Subcommittee on Personnel, Testimony on Sexual Assault in the Military, 113 th Cong , 1 st sess , March 13, 2013, S  Hrg  113-303 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , April 17, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for 2014, Part 2 , 113th Cong , 1 st sess , April 24, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , April 24, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Navy and Marine Corps , 113 th Cong , 1 st sess , May 7, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, D epartment of Defense Authorization for Appropriations for Fiscal Year 2014 and the Future Years Defense Program , 113 th Cong , 1 st sess , May 7, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Army , 113 th Cong , 1 st sess , May 8, 2013  (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Air Force , 113 th Cong , 1 st sess , May 8, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, President Obama's Fiscal 2014 Budget Proposal for the U S  Air Force , 113 th Cong , 1 st sess , May 9, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , May 22, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, Pending Legislation Regarding Sexual Assaults in the Military , 113 th Cong , 1 st sess , June 4, 2013, S  Hrg  113–320 (Washington, DC: GPO, 2013)  U S  Congress, Senate Armed Services Committee, Subcommittee on Personnel, Markup of the National Defense Authorization Act for Fiscal Year 2014 , 113 th Cong , 1 st sess , June 11, 2013 (Washington, DC: GPO, 2013)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2014 , 113th Cong , 1 st sess , June 11, 2013 (Washington, DC: GPO, 2013)  U S  Congress, House Armed Services Committee, Subcommittee on Military Personnel, Women in Service Review s , 113 th Cong , 1 st sess , July 24, 2013, H A S C  No  113–50 (Washington, DC: GPO, 2013)  U S  Congress , Senate Armed Services Committee, Subcommittee on Personnel, The Relationships Between Military Sexual Assault, Post-Traumatic Stress Disorder and Suicide, and on Department of Defense and Department of Veterans Affairs Medical Treatment and Management of Victims of Sexual Trauma , 113 th Cong , 2 nd sess , February 26, 2014, S  Hrg  113-480 (Washington, DC: GPO, 2013)   U S  Congress, Armed Services Committee , Fiscal Year 2015 National Defense Authorization Budget Request from the Department of Defense , 113 th Cong , 2 nd sess , March 6 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee, Fiscal Year 2015 National Defense Authorization Budget Request from the Department of the Navy , 113 th Cong , 2 nd sess , March 12 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for 2015, Part 1 , 113 th Cong , 2 nd sess , March 13, 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee , Fiscal Year 2015 National Defense Authorization Budget Request from the Department of the Air Force , 113 th Cong  , 2 nd sess , March 14, 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee , Fiscal Year 2015 National Defense Authorization Budget Request from the Department of the Army , 113 th Cong , 2 nd sess , March 25 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense , Department of Defense Appropriations for 2015 , 113th Cong , 2 nd sess , March 26 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Appropriations Committee, Subcommittee , Department of Defense Appropriations for 2015 , Part 2, 113 th Cong , 2 nd sess , April 2, 2014, (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense , Department of Defense Appropriations for 2015 , 113th Cong , 2 nd sess , April 2 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, House Armed Services Committee , National Defense Priorities from the Members for the Fiscal Year 2015 National Defense Authorization Act , 113 th Cong  , 2 nd sess , April 9 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2015 , 113th Cong , 2 nd sess , April 9, 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense, Department of Defense Appropriations for Fiscal Year 2015 , 113th Cong , 2 nd sess , April 30, 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Appropriations Committee, Subcommittee on Defense , Department of Defense Appropriations for 2015 , 113th Cong , 2 nd sess , June 18 , 2014 (Washington, DC: GPO, 2014)  U S  Congress, Senate Armed Services Committee , Department of Defense Authorization for Appropriations for Fiscal Year 2016 and the Future Years Defense Program , Part 1 , 114th Cong , 1 st sess , March 3 , 10 , 12 , 18 , 19, 26, April 4, 30 , 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services , Department of Defense Authorization for Appropriations for Fiscal Year 2016 and the Future Years Defense Program , Part 7 Strategic Forces, 114 th Cong , 1 st sess , March 4, 25, April 15, 22, 29 , 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services Committee, Department of Defense Authorization for Appropriations for Fiscal Year 2016 and the Future Years Defense Program , Part 3 Readiness and Management Support, 114 th Cong , 1 st sess , March 11, 25, April 22, 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services Committee, The Current State of Readiness of U S  Forces in Review of the Defense Authorization Request for Fiscal Year 2016 and the Future Years Defense Program , 114 th Cong , 1 st sess , March 25, 2015 (Washington, DC: GPO, 2015)  U S  Congress, Senate Armed Services Committee, Department of Defense Authorization for Appropriations for Fiscal Year 2017 and the Future Years Defense Program , Part 1 , 114 th Cong , 2 nd sess , February 11, 23, March 3, 10, 15, 17, April 5, 7, 26, 2016 (Washington, DC: GPO, 2016)  U S  Congress, House Armed Services Committee, The Fiscal Year 2017 Na tional Defense Authorization Budget Request from the Department of Defense , 114 th Cong , 2 nd sess , March 22, 2016 (Washington, DC: GPO, 2016)  U S  Congress, Senate Armed Services Committee, Subcommittee on Strategic Forces, The Current State of Research, Diagnosis, and Treatment for Post-Traumatic Stress Disorder and Traumatic Brain Injury , 114 th Cong , 2 nd sess , April 20, 2016 (Washington, DC: GPO, 2016)  U S  Congress, House Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2014 on H R 1960 with Additional and Dissenting Views, 113 th Cong , 1 st sess , H  Rept  113-102 (Washington, DC: GPO, 2013)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2014 to Accompany H R  2397 together with Additional Views, 113 th Cong , 1 st sess , H  Rept  113-113 (Washington, DC: GPO, 2013)  U S  Congress, Senate Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2014 to accompany S  1197, 113 th Cong , 1 st sess , S  Rept  113-44 (Washington, DC: GPO, 2013)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2014 to accompany S 1429, 113 th Cong , 1 st sess , S  Rept  113-85 (Washington, DC: GPO, 2013)  U S  Congress, House Committee on Armed Services, First Annual Report on the Activities of the Committee on Armed Services for the One Hundred Thirteenth Congress , 113 th Cong , 1 st sess , H  Rept  113-309 (Washington, DC: GPO, 2013)  U S  Congress, House Committee on Armed Services, Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015 to accompany H R 4435, 113 th Cong, 2 nd sess , H  Rept  113-446 (Washington, DC: GPO, 2014)  U S  Congress, House Committee on Armed Services, Howard P  "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015 supplemental report to accompany H R 4435, 113 th Cong  2 nd sess , H  Rept  113-446 part 2 (Washington, DC: GPO, 2014)  U S  Congress, Senate Committee on Armed Services, Carl Levin National Defense Authorization Act for Fiscal Year 2015 to accompany S 2410, 113 th Cong, 2 nd sess , S  Rept  113-176 (Washington, DC: GPO, 2014)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2015 to accompany H R 4870, 113 th Cong , 2 nd sess , H  Rept  113-473 (Washington, DC: GPO, 2014)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2015 to accompany H R 4870, 113 th Cong , 2 nd sess , S  Rept  113-211 (Washington, DC: GPO, 2014)  U S  Congress, House Committee on Armed Service, National Defense Authorization Act for Fiscal Year 2016 to accompany H R 1735, 114 th Cong , 1 st sess , H  Rept  114-102 (Washington, DC: GPO, 2015)  U S  Congress, Senate Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2016 to accompany S 1376, 114 th Cong , 1 st sess , S  Rept  114-49 (Washington, DC: GPO, 2015)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2016 to accompany H R 2685, 114 th Cong , 1 st sess , H  Rept  114-139 (Washington, DC: GPO, 2015)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2016 to accompany S 1558, 114 th Cong , 1 st sess , S  Rept  114-63 (Washington, DC: GPO, 2015)  U S  Congress, House Conference Report, National Defense Authorization Act for Fiscal Year 2016 to accompany H R 1735, 114 th Cong , 1 st sess , H  Rept  114-270 (Washington, DC: GPO, 2015)  U S  Congress, House Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2017 on H R 4909, 114 th Cong , 2 nd sess , H  Rept  114-537 (Washington, DC: GPO, 2016)  U S  Congress, Committee on Armed Services, National Defense Authorization Act for Fiscal Year 2017 to accompany S 2943, 114 th Cong, 2 nd sess , S  Rept  114-255 (Washington, DC: GPO, 2016)  U S  Congress, House Committee on Appropriations, Department of Defense Appropriations Bill, 2017 to accompany H R 5293, 114 th Cong , 2 nd sess , H  Rept  114-577 (Washington, DC: GPO, 2016)  U S  Congress, Senate Committee on Appropriations, Department of Defense Appropriations Bill, 2017 to accompany S 3000, 114 th Cong , 2 nd sess , S  Rept  114-263 (Washington, DC: GPO, 2016)  U S  Congress, House Conference Report, National Defense Authorization Act for Fiscal Year 2017 to accompany S  2943, 114 th Cong, 2 nd sess , H  Rept  114-840 (Washington, DC: GPO, 2016) 


Report 2: VA comprises a Veterans Affairs Central Office (VACO) and over 1,000 facilities and offices throughout the nation, as well as the U S  territories and the Philippines  As shown in figure 1, VA’s three major administrations are the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and National Cemetery Administration (NCA)  The largest of the administrations, in terms of workforce, is VHA and its associated Veterans Integrated Service Networks (VISN)  VHA is estimated to employ about 316,800 employees in 2017, followed by the VBA and NCA with about 22,700 and 1,850 employees, respectively  The remaining 15,000 employees are in various staff offices  VA’s budget request for fiscal year 2018 of $186 4 billion includes $82 1 billion in discretionary resources and $104 3 billion in mandatory funding  The following offices are involved in addressing misconduct at VA  Office of Human Resource Management (OHRM): OHRM develops policies with regard to performance management and assesses the effectiveness of department-wide human-resource programs and policies  Office of Accountability Review (OAR): OAR was established in 2014 within VA’s Office of General Counsel and was intended to ensure leadership accountability for improprieties related to patient scheduling and access to care, whistle-blower retaliation, and related disciplinary matters that affect public trust in VA  Office of Inspector General (OIG): The VA OIG provides oversight through independent audits, inspections, and investigations to prevent and detect criminal activity, waste, abuse, and mismanagement in VA programs and operations  Office of Accountability and Whistleblower Protection (OAWP): As required by the Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017, OAWP will take on the responsibility of, among other things, receiving whistle-blower complaints  Corporate Senior Executive Management Office (CSEMO): CSEMO supports the entire life-cycle management of VA’s senior executives by developing policy and providing corporate-level personnel services, such as training and coaching to VA’s senior executive workforce  Client Services Response Team (CSRT): CSRT serves to centralize and streamline internal processes to improve VHA’s overall responsiveness to concerns of veterans, employees, and other internal and external stakeholders  This office works closely with VA and VHA program offices and facilities to review, research, and respond to inquiries sent to the Office of the Under Secretary for Health, Office of the Secretary, and other concerns received via program offices within VACO, which lack a formalized response process  National Cemetery Administration (NCA): NCA honors veterans and their families with final resting places in national shrines that commemorate their service  NCA’s Office of Management oversees and administers all human-resource management, including activities associated with labor and employee relations  Office of the Medical Inspector (OMI): OMI is responsible for assessing the quality of VA health care through investigations of VA facilities nationwide, which include employee whistle-blower allegations referred to VA by the OSC; veteran complaints referred by the OIG, Congress, or other stakeholders; and site-specific internal reviews directed by the Office of the Under Secretary for Health  Office of Research Oversight (ORO): ORO promotes the responsible conduct of research, serves as the primary VHA office in advising the Office of the Under Secretary for Health on matters of research compliance, and is to provide oversight of compliance with VA and other federal requirements related to research misconduct  Office of Resolution Management (ORM): ORM provides Equal Employment Opportunity (EEO) discrimination complaint processing services to VA employees, applicants for employment, and former employees, which include counseling, investigation, and final agency procedural decisions  Office of Security and Law Enforcement (OS&LE): OS&LE develops policies, procedures, and standards that govern VA’s infrastructure law- enforcement program  The Law Enforcement Oversight and Criminal Investigations Division is responsible for conducting investigations of serious incidents of misconduct  Veterans Benefits Administration (VBA): VBA provides benefits and services to veterans, their families and survivors  VBA’s Office of Management directs and oversees nationwide human-resources activities and supports ORM in processing EEO complaints filed by employees and applicants who allege employment discrimination  The process for addressing employee misconduct involves various components within VA that are responsible for investigating and adjudicating allegations, as shown in figure 2  Receipt of Allegation: The OIG receives allegations of criminal activity and employee misconduct from VA employees, the OSC, members of Congress, the public, or other stakeholders  The allegations received by the OIG are initially routed to the OIG Hotline Division  The OIG also receives other types of allegations outside the scope of this review, such as issues pertaining to VA employee benefits and contracts  In addition to reporting allegations of employee misconduct to the OIG, VA employees may also report allegations of misconduct directly to their supervisors  Review and Referral of Allegation: Due to the substantial number of allegations received through the OIG Hotline Division, the OIG exercises a “right of first refusal” on misconduct cases, which allows it to take no further action, refer the case to program offices within VA for review and response, or open an investigation  For example, the OIG can either decide to (1) take no further action on matters not within the OIG’s jurisdiction or too vague to warrant further review; (2) refer allegations that warrant some action to the OMI, OAR, or VA facilities or program offices within each administration to conduct an independent review of the allegations; or (3) open cases for further review for serious allegations of criminal activity, fraud, waste, abuse, and mismanagement  Cases opened by the OIG typically involve misconduct by senior officials, or matters relating to the quality of care provided by licensed professionals  In contrast, the OIG typically refers allegations to VA facility or program offices for matters where the OIG does not have sufficient resources to open an internal case  The OIG generally does not review matters that are addressed in other legal or administrative forums, such as allegations of discrimination or whistle-blower retaliation  Notice to Employee Once Allegations Are Substantiated: The type of appointment an employee holds determines whether an employee is to be provided advance notice of planned disciplinary action once misconduct is substantiated at the conclusion of an investigation  Employees holding a permanent appointment are entitled to receive a notice of proposed action that states the specific charges for which the proposed disciplinary action is based and informs the employee of his or her right to review the material that is relied upon to support the reasons for the action  Employees in the competitive service serving in a permanent appointment (who have completed their probationary period) are treated differently than those who are still in their probationary period or serving under temporary appointments  An employee serving a probationary period or under a temporary appointment does not receive a notice of proposed action and may be immediately terminated because his or her work performance or conduct fails to demonstrate fitness or qualifications for continued employment  Temporary employees are terminated by notifying employees in writing as to why they are being separated and the effective date of the action  Disciplinary Action: VA Handbook 5021, Employee/Management Relations, governs policy for disciplinary and grievance procedures for all employees  Supervisory staff or appropriate higher-level officials use the results from investigations to help determine whether any disciplinary actions are warranted and, if so, the type and severity of each action  Other VA staff, such as human-resources and general-counsel staff may also provide guidance to management in determining appropriate disciplinary actions  After determining the facts in a case, VA may employ either disciplinary or adverse action  Adverse action involves a more- severe type of discipline (e g , removal, suspension more than 14 days, or reduction in grade) as described in table 1  As a federal agency, VA is required to report department-wide information on certain disciplinary personnel actions to the Office of Personnel Management (OPM)  OPM’s Enterprise Human Resources Integration (EHRI) system currently collects, integrates, and publishes data for executive-branch employees on a biweekly basis  This system provides federal workforce data to other government systems and the public  To adhere to this reporting requirement, VA provides information on certain disciplinary actions such as terminations and removals to OPM  The Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017 also requires the Secretary to provide a report on the disciplinary procedures and actions of the department to Congress  To understand the depth and breadth of misconduct and related issues in a large entity, such as VA, comprehensive and reliable information is needed  Standards for Internal Control in the Federal Government states that an information system represents the life cycle of information used for the entity’s operational processes that enables the entity to obtain, store, and process quality information  Therefore, management should design the entity’s information system to obtain and process information to meet each operational process’s information requirements and to respond to the entity’s objectives and risks, such as the ability to systematically analyze misconduct department-wide to identify trends and make management decisions regarding misconduct  A deficiency exists when (1) a control necessary to meet an objective is missing or (2) an existing control is not properly designed, so that even if the control operates as designed, the objective would not be met  We identified 12 fragmented information systems that VA has used, or continues to use, to collect employee misconduct and disciplinary actions  Although VA has made efforts to develop repositories to collect information pertaining to misconduct and disciplinary action, none of the 12 information systems contain complete information  Six of these systems collect partial misconduct and disciplinary action information and contain fields that could potentially be shared with other systems to obtain additional information, while the other six systems are intended for internal office use only, each containing their own unique fields and values tailored to the needs of that particular office, which are not shared  Therefore, the number of eligible fields for each information system was also limited to those not specifically designated for internal use  On the basis of our review, the 12 information systems are not currently able to communicate, or interoperate, with one another to provide a complete picture of misconduct and disciplinary actions across VA  Table 2 provides an overview of VA’s six information systems and associated data files that collect partial misconduct and disciplinary-action data that could potentially be shared with other systems  According to OHRM officials, VA’s information system for recording adverse disciplinary actions—the Personnel and Accounting Integrated Data (PAID) system—was not designed to track all misconduct cases  In addition, OHRM stated that the 53-year-old PAID system was developed primarily to track payroll actions for all employees and is the system of record that holds department-wide personnel information that is reported to OPM’s EHRI system  It contains information about adverse disciplinary actions that affect employee leave or salary, or result in a Notification of Personnel Action Form (Standard Form 50)  However, PAID does not track comprehensive information on instances of misconduct such as the offense, or the date of occurrence, and it does not include instances of other types of disciplinary actions, such as admonishments or reprimands that would not affect leave or salary, or result in a Standard Form 50  OHRM officials stated VA implemented a system called HR Smart in June 2016 that is intended to replace PAID, but the agency does not plan to upgrade the functionality of the new system to enable reliable collection of misconduct information  According to OHRM, HR Smart includes the same personnel-processing functions as PAID but will allow for tracking data changes and transaction history over time  However, as with the PAID system, adverse disciplinary actions involving leave and salary will be tracked, but other actions, such as reprimands and admonishments, will not  It also will not track information related to the offense that prompted the disciplinary action  While the HR Smart system has the capability to include modules to enhance performance features, such as the ability to track misconduct, according to OHRM officials VA does not currently have plans to implement these modules  As a result, the HR Smart system will not have the capability to track all employee misconduct department-wide and will not improve VA management’s visibility over the depth and breadth of misconduct so that it can systematically understand misconduct department-wide  VA has five additional information systems for tracking complaints or allegations of misconduct and disciplinary actions, but, similar to the agency’s PAID information system, each of these information systems contains a subset of the information that would be needed to understand all misconduct department-wide  According to Standards for Internal Control in the Federal Government, systems should include relevant data from reliable internal sources that are reasonably free from error and faithfully represent what they purport to represent  Additionally, management is advised to process data into quality information that is appropriate, current, complete, accurate, accessible, and provided on a timely basis  Management should also evaluate processed information, make revisions when necessary so that the information is quality information, and use the information to make informed decisions  Additionally, according to Standards for Internal Control in the Federal Government, management should design the entity’s information system and related control activities to achieve objectives and respond to risks  The standards add that the information system design should consider defined information requirements for each of the entity’s operational processes  Defined information requirements allow management to obtain relevant data from reliable internal and external sources  In order to achieve complete and accurate data, internal controls are needed, among other things, to ensure that fields are not left blank, data elements are clearly defined and standardized, and common data elements are included across data systems to allow for interoperability and aggregation  Our analysis of VA’s 14 data files identified the following three categories that reduced the reliability of the data: lack of data standardization, and lack of identifiers  We found that 7 data files we reviewed contained a majority of data within fields, but 5 data files were missing a significant amount of data within certain fields  We were unable to analyze the remaining two files due to a number of data-quality issues  Among the fields that were missing data were several that would be useful for analyzing misconduct, including complainant name, proposed action, and person of interest, as shown in table 4  For example, we found that in the OAR Legacy Referral Tracking List, 97 percent of the entries for the Proposed Action field (1,210 of 1,245) and 96 percent for the Disciplinary Action field (1,190 of 1,245) were blank  If available, comparison of the proposed and disciplinary action-taken fields would allow VA to assess whether actions are consistently implemented department-wide  However, the high percentages of blank values in multiple fields impair VA’s ability to conduct a comprehensive analysis of misconduct to identify and address trends  See appendix II for a further listing of the five data files and the corresponding fields that were missing data  In addition, we found that several data files had options such as “not applicable” or “no” for certain fields so that the field would not be left blank, but these options were not consistently used  For example, the Complainant Name field within the Legacy Referral Tracking List was blank for some entries and not applicable (N/A) for others  Accordingly, we did not know whether data were intentionally omitted or not entered by mistake  In addition, the Offense Sustained field found within the VA-Wide Adverse Employment Action and Performance Improvement Plan Database was blank for some entries and either a yes or no for others  Eight of the 14 data files we reviewed did not have key data elements that were defined within and across information systems  In other words, the data files contained entries that described similar information in different ways  For example: The Complaints Automated Tracking System (CATS) Employment data were not mutually exclusive, or independent of one another  For example, this field includes two distinct categories of information: employment status, such as full time or part time; or hiring authority, such as Title 5 or Title 38  This method of storing information resulted in undercounting each of the separate values due to the system’s inability to account for expected overlap  For instance, an employee could be both a full-time and Title 5 employee and the field only tracks one or the other  ORM officials stated that this field has since been modified to capture more options to account for the overlap  The NCA data file’s Action Proposed/Decided/Taken data were tracked in a single field and updated with the most-recent action, rather than capturing proposed actions, decided actions, and actions taken in separate fields  We also identified standardization issues with the newly updated VA- Wide Adverse Employment Action and Performance Improvement Plan Database  For example, we found 15 different variations of Registered Nurse, such as “Registered Nurse,” “Staff RN,” and “RN” position names  In addition, we found 28 alternate values that identified Diagnostic Radiologic Technologists (e g , Diagnostic Radiologic Technologist, Diagnostic Radiological Technologist, and Radiologic Technologist)  See appendix III for a description of the fields that did not have standardization within the eight data files  We determined that 5 out of the 14 data files did not have identifiers that would allow comparisons of information across systems  Identifiers are important because they reference one unique individual or case, which makes it possible to analyze historical data pertaining to all records with the same identifier and analyze trends in employee misconduct over time  For example: The OAR VA-Wide Adverse Employment Action Database and the VBA data files had a combined total of 4,487 closed cases of misconduct that received adverse corrective action during the combined period of November 2013 through December 2016  We found that these two data files did not contain unique identifiers for complainants or accused individuals for a given case  OAR officials stated that this system does not contain Personal Identifying Information since its purpose is to track proposed and taken adverse actions  If more-specific information is needed, OAR staff coordinate with the human-resource point of contact  Although OAR may obtain additional information, this information is not entered into the OAR VA-Wide Adverse Employment Action Database, which would assist with conducting analysis  VAPS tracks misconduct in two separate subsystems, one of which tracks traffic violations and other administrative offenses, and one of which also tracks more-egregious offenses such as criminal violations  These subsystems also do not have unique identifiers that would allow data matching between the two subsystems, which could impede the analysis of this information  Even with both files, there is no ready way to capture the complete number of individuals with misconduct in both files due to the lack of a shared identifier  The newly updated VA-Wide Adverse Employment Action and Performance Improvement Plan Database does not contain unique identifiers, such as employee identification number, name of the complainant or accused, or other linking variables, to allow for the analysis of historical trends or comparison of information among other information systems  The data-quality issues described above are due in part to most of VA information systems not having data dictionaries, field definitions, or other documented guidance and procedures on data entry and automated edit checks to control for erroneous entries and blank fields  Absent guidance and procedures, VA lacks assurance that employees will enter complete and accurate information in the various data systems  Further, the lack of unique identifiers such as employee identification number, case number, or other linking variables for each of the records does not allow for analysis of historical trends or comparison of information among different information systems  Consequently, this precludes VA from determining the frequency and nature of allegations by specified category, or identifying trends, thus impeding senior officials’ ability to analyze misconduct department-wide and develop corrective actions  VA Directive 5021, Employee/Management Relations, governs policy for disciplinary procedures for all employees and outlines the provisions for the adjudication of each disciplinary action and associated file documentation requirements  Specifically, files must be established before a notice of proposed adverse action is issued to the employee to document that the adjudication procedures were followed  The file must contain all available evidence upon which the notice of proposed action is based and that supports the reasons in that notice  In addition, each file should contain specific documentation related to the adjudication of employee misconduct  VA Handbook 5021 states that disciplinary actions and associated adjudication procedures for all VA employees appointed under Title 5 are governed by three basic principles: (1) an employee shall be informed in writing honestly and specifically why the action is being brought against him or her; (2) an employee shall be given a reasonable opportunity to present his or her side of the case; and (3) the employee and representative shall have assurance of freedom from restraint, interference, coercion, discrimination, or reprisal in discussing, preparing, and presenting a defense  Our review of a generalizable sample of 544 misconduct case files (from a universe of 23,622 files) associated with disciplinary actions that affect pay from October 2009 through May 2015 revealed that VA officials did not consistently adhere to VA’s policy for retaining files containing evidence of misconduct  Specifically, VA was unable to provide the files for 10 percent (55 of 544) of the files we requested  We determined that administrations and program offices within VA have various record- retention schedules  Offices that have not established a record-retention schedule refer to the general records schedule developed by the National Archives and Records Administration (NARA)  However, we found that some offices are misinterpreting OPM and NARA guidance and specify the record retention period for adverse action files as a range between 4 to 7 years rather than selecting a specific number of years in their record- retention schedules  All of the files were within VA’s record-retention range specified during the time of our review  The files that were unaccounted for were dispersed throughout most of the VISNs, but one VISN was not able to account for 19 of the missing files in our sample  On the basis of our weighted analysis of the generalizable sample, we estimate that VA would not be able to account for approximately 1,800 files in the full population that were within the record-retention period specified  In addition, VA officials did not consistently adhere to VA’s policy for documenting that procedures were followed in the adjudication of misconduct cases  We identified 22 out of 36 file requirements where VA was not able to consistently demonstrate compliance with VA policy due to the lack of documentation contained in files, based on our generalizable sample  Specific to both Title 5 and Title 38 permanent- employee misconduct case files, table 5 shows the estimated number and percentage that deviated from file documentation requirements  A list of the 22 identified requirements and the percentage of files not in compliance can be found in appendix IV  As table 5 indicates, Title 5 and Title 38 permanent employee files did not always contain documentation that employees were informed of the reason the action was brought against them  For example, on the basis of our generalizable sample, we estimate that the advance notice of proposed action, which includes a statement of the specific alleged misconduct upon which the proposed action is based, was not included in 16 percent of the files department-wide  A final decision letter, which contains a statement of the decision official’s determination regarding which charges, if any, in the advance notice were sustained, was not included for an estimated 15 percent of all files  Further, an estimated 35 percent of all files did not include a written acknowledgement from the employees that they received the final decision letter in person, and an estimated 23 percent of all files did not include the required return receipt for certified mail indicating that the decision letter was mailed to the employee  In addition, Title 5 and Title 38 permanent employee files did not always contain documentation that employees were provided a reasonable opportunity to present their side of the case  Our review found that permanent-employee disciplinary files did not adhere to basic principles outlined in VA Handbook 5021 and lacked evidence to demonstrate that employees were adequately informed regarding their rights during the adjudication procedure  Specifically, our generalizable sample found that an estimated 21 percent of all files did not include statements regarding the employee’s rights to due process, such as his or her entitlement to be represented by an attorney or other representative  In addition, an estimated 8 percent of all files did not mention that more information regarding appeal rights could be obtained by consulting Human Resources Management offices  For files where the employee provided an oral reply in response to proposed disciplinary action, an estimated 29 percent of files did not include the required written summary, which is to be signed by the official hearing the oral reply  Where a written reply was submitted, an estimated 11 percent of files did not include a copy of the employee’s written reply  Further, VA officials did not consistently adhere to VA’s best practices specific to Title 5 permanent employees only  We found that in a majority of these files (an estimated 72 percent) the proposal letters did not include a statement that assured the employee he or she had freedom from restraint, discrimination, or reprisal in discussing, preparing, and presenting a defense  VA Handbook 5021, Employee/Management Relations, also states that Title 5 employees should provide their written responses through supervisory channels to the decision official  We estimate that a total of 6,819 files (47 percent) of Title 5 permanent employee files did not provide their written reply through supervisory channels to the decision official  Although OHRM is responsible for assessing the effectiveness of department-wide human resource programs and policies of VA Handbook 5021, according to OHRM officials, each facility is responsible for oversight of implementing policies and guidelines pertaining to how disciplinary actions are processed  We found no evidence that OHRM has assessed whether documentation exists that demonstrates adherence to policy governing cases involving disciplinary actions or provided oversight of VA’s implementation of record-retention requirements, or that human- resource personnel adhere to basic principles outlined in policy to ensure employees are informed of their rights during the adjudication process  The resulting lack of oversight to HR policies increases the risk that employees will not be adequately informed of their rights during the adjudication process  Accordingly, employees may not (1) be provided with information on why an action is being brought against them, (2) be provided with a reasonable opportunity to present their case, and (3) be adequately protected from potential reprisal in preparing their defense  Regarding retention of records, according to NARA, disciplinary and adverse action case files should be destroyed no sooner than 4 years but no later than 7 years after the case is closed  According to OPM, to implement this authority, each agency must select one fixed retention period between 4 and 7 years and publish the retention in the agency’s records disposition manual  We determined that some offices are misinterpreting OPM and NARA guidance by not selecting a specific number of years in their record- retention schedules  For example, three of the six policy record-retention schedules we reviewed did not establish a specific number of years for record retention  Specifically, record-retention policies for the Office of Information and Technology, VACO staff offices, and VBA specified the record-retention period for adverse action files as a range between 4 to 7 years rather than selecting a fixed retention period  For example, we found that the Records Control Schedule pertinent to VACO was dated June 30, 1967, without references to new or revised items since 1969  Our results are consistent with an October 2016 inspection conducted by NARA  The inspection report contained 16 findings and 19 recommendations for improvement of the records-management program at VA  Among the findings and recommendations were the following  Finding: The VA records management program has not ensured that the VACO maintains a current Records Management Handbook and a current Records Control Schedule, which together establish program objectives, responsibilities, and authorities for the creation, maintenance, and disposition of agency records  Recommendation: The Department Records Office must update and maintain the VACO handbook and the Records Control Schedule for Central Office Staff Offices and the Offices of the Assistant Secretaries to include specific Records Management roles and responsibilities for all VACO staff and to include mandates for implementation of records management policies and procedures in accordance with Federal statutes and regulations  Finding: The VA Departmental Records Management program does not conduct regular records management evaluations within VACO and the Offices of the Secretary and Assistant Secretaries or monitor the oversight activities of the Administrations  Recommendation: The VA Departmental Records Management program, working with the Administrations, VACO, and Enterprise Risk Management, must establish effective Records Management evaluation programs to monitor VA compliance with Federal regulations  Recommendation: The VA Departmental Records Management program, working with the Senior Agency Official for Records Management, must establish effective Records Management evaluation programs to monitor the records management practices within the Office of the Secretary and Assistant Secretaries to ensure compliance with Federal regulations  Finding: VACO Staff Offices and the Offices of the Assistant Secretaries are not routinely conducting records inventories  Recommendation: VACO Staff Offices and the Offices of the Assistant Secretaries, with support from the Department Records Management program, must conduct inventories of existing electronic and non-electronic records to identify scheduled, unscheduled, and vital records  In response to NARA findings, VA is to submit a plan of corrective action that specifies how the agency will address each inspection report recommendation, including a timeline for completion and proposed progress reporting dates  VA does not have a method in place to evaluate the implementation of records-management practices outside of those being conducted by VHA and VBA  Accordingly, VA has not been conducting records-management oversight with any uniformity department-wide  Further, VA’s use of multiple retention periods for adverse action files, and in some cases the lack of adherence to OPM and NARA guidance in defining a specific retention period for these files, results in inconsistent retention of these files across VA  The OIG receives allegations of employee misconduct from VA employees, the OSC, members of Congress, the public, and other stakeholders  When the OIG receives allegations it can either take no further action, open an investigation, or refer the case to facility or program offices within VA for review and response  For cases referred to facility or program offices, the OIG has developed a policy for VA facilities and program offices to use when investigating allegations of misconduct  This policy includes six elements that VA facility and program officials are to incorporate in their investigations, as shown in table 6  According to OIG officials, if the reviewing employees have concerns about the adequacy of the response provided, the OIG can either ask for additional information to supplement the response or open an internal case  Departmental heads (Under Secretaries for Health, Benefits, and Memorial Affairs, Assistant Secretaries, and other key officials) are responsible for ensuring that referrals are properly reviewed, documented, and answered within specified time frames  Our review of the 23 OIG cases of alleged misconduct between calendar years 2011 and 2014 involving senior officials found that VA facility and program offices did not consistently follow policies and procedures established by the OIG for investigating such allegations  In several instances, VA facility and program offices did not include one or more of the six elements required in their investigative response to allegations of misconduct  In addition, our review of the 23 cases found instances in which VA facility and program offices did not include sufficient documentation for their findings, or provide a timely response to the OIG  The OIG was not able to produce the documentation provided by the facility or program office that was used to close 2 of the 23 cases in our review  All of the requested files were within the OIG’s 7-year record- retention period during the time of our review  As shown in table 7, we identified four cases that did not contain evidence of an independent review by an official separate from and at a higher pay grade than the accused  In three of the four cases that were not reviewed by an independent official at a higher grade, the review was performed by the medical center director, who was one of the accused named in the allegation  For example, in one case involving alleged time-and-attendance abuse by a physician, the medical center director, who was also named in the allegation as having received a similar complaint against the physician 2 years earlier, reviewed the allegations made against the physician and himself  The documentation provided showed that the medical center director conducted the investigation of allegations and found the allegations were not substantiated and no corrective actions were implemented  In all four cases, both the independence and higher-grade criteria were not followed when the accused senior officials investigated allegations against themselves  As shown in table 8, we generally found that VA facility and program offices reviewed each allegation contained in the original referrals, although in one case the reviewer did not respond directly to all allegations  As shown in table 9, VA facility and program offices clearly indicated their findings for each allegation in 14 of the 21 cases of misconduct involving senior officials for which files could be located, as well as their assessment of whether the allegations were substantiated or unsubstantiated  However, we identified seven cases in which VA discussed its findings but did not provide a clear indication of whether all allegations were substantiated or unsubstantiated  Responses lacking a clear statement of substantiation may be more difficult for subsequent reviewers, including OIG and OAR investigators, to track and perform follow-up where necessary  For example, in one case involving 11 allegations, no statement of substantiation was provided, but VA’s response included seven recommendations, three of which involved disciplinary action  We did not find evidence in the case file that follow-up was performed by the OIG personnel to clarify this discrepancy, and the case was closed  As shown in table 10, most allegations involving senior officials (16 of 21 cases for which files could be found) were not formally substantiated and did not require a recommendation for corrective action based on OIG case-referral criteria  Specifically, the criteria require a description of corrective actions taken or proposed as a result of substantiated allegations, but make no mention of allegations that were not substantiated as part of VA’s response  For one substantiated allegation, however, we found no evidence of a recommendation for corrective action  Table 11 shows that 17 cases from VA facility and program offices did not provide the supporting documentation they used to reach their conclusions about the OIG case referrals  In 17 cases, including one case reviewed by an AIB panel, VA referenced documents reviewed but did not attach any of the supporting evidence  OIG case-referral criteria state that VA facility or program offices must provide supporting documentation used in their review, such as copies of pertinent documents  However, the criteria do not specify whether copies of all documentation reviewed must be included in the file  Supporting documentation, which must be provided according to OIG policy, will vary depending on the circumstances of the case, but those used to support the findings and recommendations should be included  For example, we reviewed one case where pertinent documents were referenced to support the allegation, but documents supporting the findings and recommendation were not included  The case contained allegations involving false patient wait-time documentation and abuse of authority  Specifically, a medical center director instructed staff to review patient wait times between follow-up appointments in order to meet VA’s 14-day timeliness metric  The investigation revealed that VA staff had changed several hundred veteran appointment wait times  The investigation concluded that the false documentation allegation was substantiated, but attributed the cause to the staff not understanding how to enter a follow-up appointment date into the system  However, there was no documentation in the files to support (1) that the medical center director had not abused his authority by instructing staff to review wait times greater than 14 days to determine how they could be reduced, and (2) findings for the conclusion that the original wait times were entered in error  Absent supporting documentation, it is difficult for the OIG to determine whether enough evidence was gathered before closing alleged cases of misconduct that were found to be unsubstantiated or closing substantiated cases of misconduct that required further action  VA Directive 0701 states that copies of voluminous transcripts of interviews, the entire claims folder, and medical charts are not necessary  However, VA Directive 0701 further states that such materials should be available if the OIG subsequently requests them within the record-retention period  Case examples of allegations reviewed, and subsequently closed, by the VA OIG based on its evaluation of evidence provided by facility and program offices in response to allegations of misconduct can be found in appendix V  As shown in table 12, VA facilities’ or program offices’ response letters, which were sent to the OIG, included a point of contact for further questions in 15 of the 21 OIG case referrals involving senior officials, including the individual’s name and a means of contact (phone or e-mail)  In 2 of the 15 cases where a point of contact was provided, the contact was also one of the accused in the allegation  Although that is not technically a violation of OIG criteria, it likely presents a conflict of interest in regard to independent reviewers obtaining objective case information  In six other cases, no contact was listed, although the letter was signed by the reviewer  If a specific point of contact is not identified, including position title, it may be assumed erroneously by employees involved in the case, or following up on the case, that the default contact is the reviewer, who may not be the appropriate point of contact, and may or may not be able to provide objective case information  OIG guidelines state that VA facilities and program offices assigned Hotline case referrals are responsible for reporting written findings to the Hotline Division within 60 days, unless an extension is requested  Our review of the 21 cases found instances in which VA facility or program offices did not always provide a timely response to the OIG  Table 13 shows five instances in which VA facility or program offices submitted a response after the deadline requested by the OIG  One response was not reported timely after an extension was provided by the OIG  In one of the five cases involving allegations of abuse of authority by a VA medical center director, the reviewer requested an extension, which is permitted by OIG policy, but still missed the revised deadline  The five case files did not contain any information regarding any follow-up actions taken in response to delays  According to OIG officials, when a case has been referred to a program office for investigation, the OIG reviews the program office’s response for completeness and sufficiency before closing the case  However, there is no requirement for the OIG to ensure that the responses contain the six elements listed in VA Directive 0701 and confirm that case referral allegations have been addressed  Consequently, the lack of verification could have contributed to insufficient evidence that does not meet the requirements outlined by the OIG  Additionally, VA facility and program offices have not consistently adhered to VA Directive 0701 policy and do not always provide supporting documentation for their findings and recommendations, or always provide a timely response when reporting findings to the OIG’s Hotline division  Inconsistent adherence to the reporting standards provided by the OIG to VA facilities and program offices for investigating and resolving misconduct case referrals from the OIG Hotline impedes VA’s ability to ensure that misconduct cases are being handled appropriately  According to OIG officials, the OIG has taken steps to enhance the review of case responses  Specifically, OIG officials stated that in April 2018 the OIG implemented a new Enterprise Management System to reduce reliance on certain manual processes  According to OIG officials, Hotline analysts will now have more time to review their work and perform other quality-assurance activities  In implementing this new system, it will be important for the OIG to consider how the system can assist in ensuring requirements are met and responses are received timely  Our review of VA’s information systems that track misconduct involving senior officials department-wide indicates that they may not always be held accountable for misconduct  Specifically, (1) misconduct was sometimes substantiated, but the proposed disciplinary action was not taken; (2) misconduct was sometimes substantiated, but no disciplinary action was recommended; (3) previous penalties did not have the corrective effect for officials found to have engaged in repeated acts of misconduct and who have remained in VA management positions; and (4) senior officials violated separation-of-duty policy when taking disciplinary action  VA Handbook 5021 allows the deciding official to determine the appropriate disciplinary action if one or more allegations are substantiated  However, the disciplinary action may not be more severe than what had been proposed  In several cases, misconduct was substantiated, but the proposed action was not always taken  Our review of the OAR Legacy Referral Tracking List identified 17 officials between calendar year 2011 through May 2015 with substantiated misconduct where action was proposed  However, in some of these cases, the officials were given a lesser penalty than the one proposed, while in other cases there is no evidence that action was taken  As shown in figure 3, we found that for 12 of the 17 officials with substantiated misconduct, an adverse disciplinary action (removal) was proposed  Of those 12 officials, 3 were removed, 2 received a suspension, 4 received a reprimand or admonishment, 2 were allowed to resign or retire before receiving disciplinary action, and we found no evidence of disciplinary action for the remaining individual  For the other 5 officials, actions such as counseling, admonishment, suspension, or reprimand were proposed  Of the 5 officials, 2 received the actions that were proposed, 1 received a lesser penalty than what had been proposed, 1 was allowed to retire before receiving action, and we found no evidence of the proposed action for the remaining individual  For the two officials for whom there was no evidence that disciplinary action was taken, we found no evidence within the PAID information system or personnel files that these officials received the action proposed in the OAR Legacy Referral Tracking List  Counseling was proposed for one official, and removal from the position for the other official  OAR did not provide us with evidence that the officials had received the action proposed  We also reviewed an additional 15 cases that involved a fact-finding or an AIB  Our review of these cases found that 11 out of 23 officials were associated with instances of substantiated misconduct and proposed action was recommended  For 4 of the 23 officials where the proposed action field was populated, the information within the OAR Legacy Referral Tracking List reflected the action recommended  The applicable data fields for the remaining 19 officials within the OAR Legacy Referral Tracking List were not in agreement with the action recommended, or blank  This review also identified two officials with substantiated misconduct where OAR did not provide evidence that the disciplinary action proposed was taken: Two officials were involved in a case concerning alleged whistle- blower retaliation at the Phoenix VA Health Care System  The investigative report documented that allegations were sustained  The retaliation included allegations of involuntary reassigning the whistle- blower to another position, placement of the whistle-blower on administrative leave, and lowered performance pay ratings following disclosures regarding poor patient care and nursing triage errors  Appropriate administrative action for persons identified as having engaged in retaliation was recommended  We did not find any evidence in the PAID system that these two officials involved in retaliation received disciplinary action  OAR provided documentation to show that no action was taken against one official, and was unable to provide documentation to show that the disciplinary action had been taken for the other  The official who received no action received approximately $11,500 in performance pay during a 2-year period following the allegations  OAR’s quality-review process for investigative reports does not ensure that reports with findings of substantiated misconduct include recommendations for action  Our review of OAR’s Legacy Referral Tracking List identified 70 out of 1,245 closed cases involving officials where misconduct was either substantiated, or partially substantiated, but no disciplinary action was recommended  One case involved three allegations of poor dental care provided to patients by three different senior officials  One physician cut underneath a patient’s tongue with the bur of a hand-piece drill (substantiated), another administered medication the patient was allergic to (partially substantiated), and the final senior official extracted the wrong tooth (substantiated)  We did not find any evidence in the PAID system that these senior officials received disciplinary action  Further, OAR did not provide documentation to show that any disciplinary action had been proposed or taken  The physician that cut underneath a patient’s tongue received performance pay totaling $15,000 approximately 6 days after the investigation had concluded that misconduct was substantiated  As of March 2018, two of these senior officials received performance pay, and appear to still be employed at VA  While an investigation was conducted that substantiated (or partially substantiated) the allegations, there is an increased risk that some substantiated misconduct will go unaddressed if there is no recommendation for corrective action  Our review of OAR’s Legacy Referral Tracking List indicated that some officials who had been disciplined for misconduct remained in positions where they were responsible for proposing or deciding disciplinary action for other employees  We identified 15 officials in the OAR VA-Wide Adverse Employment Action Database who received disciplinary action between 14 days to 1 year prior to proposing disciplinary action for another employee  Most of the 15 officials (12 officials) had received a suspension  We also found that five officials in the OAR Legacy Referral Tracking List had received prior disciplinary actions for offenses unrelated to the new OAR allegations  A prior history of disciplinary actions indicates that some officials may be repeat offenders for whom the previous penalties did not have the desired corrective effect  For example, 4 out of 5 officials were suspended for a different offense prior to being the subject of a new allegation  One of the four officials was suspended less than 2 months prior to being the subject of a new allegation, while another received a suspension before, and again approximately 7 months following, the OAR allegation  According to VA Handbook 5021, the deciding official must use the “Douglas” factors, which include the employee’s past disciplinary record, to determine a reasonable penalty  One of the five VA officials was eventually removed approximately 6 months after the new OAR allegation  In analyzing cases involving senior management, we noted that the OAR Legacy Referral Tracking List often did not accurately reflect the disciplinary action that was decided based on the results of the investigation  In numerous instances for the OAR Legacy Referral Tracking List, the applicable data fields indicating the proposed and final disciplinary action were blank  In these cases where the disciplinary fields were populated, the data usually did not agree  Specifically, for 32 out of the 40 records we reviewed where misconduct was substantiated, the final disciplinary action taken did not reflect the information within the OAR Legacy Referral Tracking List  When disciplinary actions are taken in response to findings of misconduct but are not entered within an appropriate information system, or are inaccurately recorded, it is more difficult to (1) monitor whether disciplinary actions have been implemented, and (2) ensure information relevant to management for making decisions is available  Further, without a prior record of misconduct or disciplinary action, senior officials who are repeat offenders may not receive the appropriate penalty required  Pursuant to the Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017, OAWP will now be responsible for receiving, reviewing, and investigating allegations of misconduct, retaliation, or poor performance involving senior officials  According to OAWP officials, their office investigates allegations of misconduct at the senior level only  OAWP officials also stated that misconduct issues that occur below the senior level will be referred to each of the three major VA administrations for investigation and resolution  In addition to the VA- Wide Adverse Employment Action and Performance Improvement Plan Database, OAWP officials stated that it has implemented two additional information systems that are used concurrently to capture case information  OAWP officials stated that they are currently working with VA Information Technology to assess options for other case-management systems that could consolidate these three information systems into one comprehensive system  VA Handbook 5021, Employee/Management Relations, states that the decision on a proposed major adverse action will be made by an official who is in a higher position than the official who proposed the action, unless the action is proposed by the Secretary  Standards for Internal Control in the Federal Government states that management should divide or segregate duties among different people  Our review of the OAR VA-Wide Adverse Employment Action Database, OAWP VA-Wide Adverse Employment Action and Performance Improvement Plan Database, and VBA data file identified examples where VA officials did not follow separation-of-duty requirements  As shown in table 14, 73 (out of an estimated 7,886) VA officials acted as both the proposing and deciding official in cases involving removals for employees found to have engaged in misconduct  Fourteen VA officials acted as both the proposing and deciding official in two or more cases  One of these 14 officials acted as both the proposing and deciding official for seven different removal cases  Further, our review of 29 VA officials found that none received disciplinary action for violating separation-of-duty policy  The systemic lack of adherence to VA’s separation-of-duty policy is reflective of a lack of controls that would allow such activity to occur  Focusing on ensuring such controls are implemented would help ensure that VA decreases the risk of abuse when officials act as both proposing and deciding officials  VA has procedures in place to ensure that allegations of misconduct are investigated, but these procedures allow VA program offices or facilities where a whistle-blower has reported misconduct to conduct the investigation  According to VA officials, investigations that are deemed necessary are occasionally ordered directly from the head of the facility or VA leadership, which takes the lead on an investigation into the allegation  Alternatively, an OIG official stated if allegations of misconduct are received by the OIG, the OIG has the option of investigating the allegation or exercising a “right of first refusal” whereby it refers allegations of misconduct to VA facilities or program offices where the allegation originated to complete an independent review and provide a response to the OIG  As shown in figure 4, the majority of contacts the OIG received (127,265 out of 133,435) from calendar years 2010 through 2014 were not investigated due to several reasons, such as insufficient evidence or lack of jurisdiction  Of those contacts that were investigated, the majority (4,208 of 6,170 investigated contacts) were not investigated by the OIG but rather were referred to facility or program offices for investigation  Whistle-blowers also have the option of reporting alleged misconduct outside VA by filing a disclosure with the OSC, and may do so if they believe there has not been a resolution to their complaint internally  If the OSC determines that there is substantial likelihood of wrongdoing, it may refer the disclosure back to the Secretary of Veterans Affairs for further investigation  According to OSC officials, as a general policy, the OSC will not refer a disclosure to the Secretary if the OIG is already conducting an investigation of that particular complaint and defers to the OIG to finalize the investigation  According to OIG officials, the OIG may, in turn, exercise its “right of first refusal” when cases are referred from the OSC  Consequently, this process can result in a disclosure that was originally made to the OSC being referred back to the facility or program office where the allegation originated  As shown in figure 4, the OSC referred 172 of 942 disclosures (18 percent) filed by VA employees back to the Secretary of Veterans Affairs for further investigation from calendar years 2010 through 2014  Of the 172 disclosures referred, VA referred 53 back to the facility or program offices where the complaint originated and 119 to the OIG  The independence of officials conducting or reviewing the results is paramount to the integrity of the process both in deed and appearance  According to VA Directive 0700, the decision whether to conduct an investigation should not be made by an official who may be a subject of the investigation, or who appears to have a personal stake or bias in the matter to be investigated  Moreover, according to OIG policy, investigations referred to VA offices must be reviewed by an official independent of and at least one level above the individual involved in the allegation  VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence  VA OIG officials acknowledged that there have been concerns about referring cases back to the chain of command because the OIG is unsure where cases go once they are referred  The investigation of allegations of misconduct by the program office or facility where the complaint originated may present the appearance of a conflict of interest in which managers and staff at facilities may investigate themselves or other allegations where they may have a personal stake or bias in the matter to be investigated  Consequently, there may be an increased risk that the results of the investigation are minimized, not handled adequately, or questioned by the OSC or the individual who made the original allegation  According to VA Directive 0700, significant incidents occurring, and issues arising, within VA facilities or offices shall be reported and investigated as necessary to meet the informational and decision-making needs of VA  Primary responsibility in this regard rests with the chief executives of the facility or staff office involved, and with their supervisors in VA and its administrations  According to an OIG official, VA (the Secretary or a delegate) sends disclosures received from the OSC to the OIG, which may then refer to VA facility or program offices for further review and investigation  According to OSC officials, for cases that are referred to a program office, the OSC requires that the Secretary or delegate provide a report that outlines its conclusions and findings  This reporting is not required for disclosures where an ongoing OIG investigation is already under way  According to OSC officials, for each disclosure, the OSC is to review the report for statutory sufficiency and determine whether the findings of the agency head appear reasonable  The OSC is to send its final determination, report, and any comments made by the whistle-blower to the President and responsible congressional oversight committees  The OSC has raised concerns in its reports to the President about investigations conducted by VA program offices and facilities  Of the 172 whistle-blower disclosures referred by the OSC between calendar years 2010 through 2014, the Secretary of Veterans Affairs referred 53 to facility and program offices  Our review of these 53 OSC reports found that the OSC had concerns about the conclusions VA reached in 21 (40 percent) of the 53 disclosure cases  For example, the OSC found that the conclusions in some VA reports were unreasonable because VA reached its conclusion without interviewing the witness, provided shifting explanations that strained credibility and did not provide evidence of an unbiased investigation, ignored whistle-blower concerns by refusing to investigate allegations, and refused to acknowledge the impact on the health and safety of veterans seeking care after confirming problems in these areas  For disclosure cases that were referred from the OIG to facility and program offices during the 2010–2014 time frame of our review, the OIG acknowledged that these concerns arose because of a lack of communication between the department and the OIG regarding the scope of the review  At the time of our review, VA did not have a procedure in place to ensure the conclusions reached for investigations involving OSC disclosure cases are reasonable and meet the informational and decision- making needs of VA whereby all allegations are addressed  More recently, the OIG has started to communicate the scope of its reviews that involve matters referred by the OSC to the Office of the Secretary  In implementing this new process, it will be important for the Office of the Secretary to ensure that any allegations outside the purview of the OIG’s investigation are fully addressed by a departmental entity in accordance with OSC requirements  As shown in figure 4, of the 172 disclosure cases referred to VA by the OSC, a total of 119 cases were referred to the OIG  The OIG had conducted, or was already conducting, an investigation of the particular allegations for all 119 disclosures  Since these 119 disclosure cases were already under investigation by the OIG, the OSC deferred to the OIG’s investigation for these cases  A total of 37 of these 119 disclosure cases that were referred to the VA OIG were submitted to the OSC anonymously  Therefore, we were unable to conduct a review of these investigations because there was no information available to identify the individuals involved  According to Standards for Internal Control in the Federal Government, management’s ability to make informed decisions is affected by the quality of information  Accordingly, the information should be appropriate, timely, current, accurate, and accessible  The oversight body oversees management’s design, implementation, and operation of the entity’s organizational structure so that the processes necessary to enable the oversight body to fulfill its responsibilities exist and are operating effectively  Our review of the remaining 82 disclosure cases determined that the OIG does not have procedures in place to track cases that were referred from the OSC for further investigation  According to OIG officials, the OIG’s information system did not have a method in place to ensure that OSC case numbers are linked to the OIG investigative case number and final report  Consequently, the OIG was unable to produce the investigative documentation for these 82 disclosures  According to OIG officials, OSC case numbers and associated Hotline numbers are currently tracked in a spreadsheet until the implementation of a new system  The inability to locate investigative documentation prevents a third party from verifying whether the OIG examined the disclosures, whether any recommendations were addressed, or whether appropriate disciplinary action was taken for these cases  In addition, because the OSC defers to the OIG’s investigation for allegations that were already conducted, or being conducted, the OSC and individuals that made the allegations do not have documentation to demonstrate that the allegations were addressed  This information, or lack of it, has direct influence on management’s ability to make sound decisions relating to investigative matters  Pursuant to the Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017, OAWP will be responsible for recording, tracking, reviewing, and confirming implementation of recommendations from audits and investigations involving whistle-blower disclosures, including the imposition of disciplinary actions and other corrective actions contained in such recommendations  According to OAWP officials, the whistle-blower disclosure process will be similar to the current process when cases are referred to facility and program offices for investigation  OAWP will follow up on any open points with the level of leadership that is most appropriate in each case, such as the medical center or VISN director  Case details will be tracked through the three active databases that are being used concurrently  OAWP is currently working to develop an internal process that will bring the investigative communities together  For instance, OAWP would like to monitor cases that are referred to VA facility and program offices, but it does not currently have documented criteria to guide the process  According to OAWP officials, OAWP is finalizing new policies in the form of a policy manual and handbook  However, these officials were unable to provide a time frame for completion of the published guidance  Our analysis of VA data shows that individuals who filed a disclosure of misconduct with the OSC received disciplinary action, and left the agency, at a higher rate than the peer average for the rest of VA  We identified 135 disclosure cases that were received by the OSC between calendar years 2010 and 2014 and were alleging misconduct  Of the 135 disclosures, a total of 129 employees made a total of 130 disclosures nonanonymously  We compared the 129 employees who made nonanonymous disclosures to the PAID information system using the complainants’ information  As shown in table 15, on average approximately 1 percent of all employees in the VA roster received an adverse action in any given fiscal year  For the 129 nonanonymous whistle-blowers, we found that approximately 2 percent received an adverse action in the fiscal year prior to their disclosure, while 10 percent had received an adverse action in the fiscal year of their disclosure, and 8 percent received an adverse action in the year subsequent to this disclosure  While the fact that nonanonymous whistle-blowers faced higher rates of adverse action subsequent to their disclosure than the VA population as a whole is consistent with a pattern of retaliation for nonanonymous whistle-blowers, it is only an indication that retaliation could be occurring  Our analysis also showed that among employees who could be matched to the PAID end-of-year roster, attrition rates were higher for those individuals who filed a nonanonymous disclosure with the OSC  On average, approximately 9 percent of all VA employees on the end-of-year roster in one fiscal year were not on the subsequent year’s roster  In contrast, 66 percent of the 129 nonanonymous whistle-blowers did not appear in the subsequent year’s roster  Attrition rates were higher among employees who had filed a disclosure than among their peers who had not filed disclosures, for all fiscal years in our review (see table 16)  Our analysis did not confirm the reasons for disciplinary action or attrition involving any of the 129 employees who made nonanonymous disclosures to the OSC  According to VA officials, employees who have a history of poor performance or conduct may be more likely to file a disclosure with the OSC or allege misconduct, which could explain some of the disparities between whistle-blowers and other employees  However, we also could not rule out instances where retaliation by senior officials may have occurred after misconduct was disclosed  The Civil Service Reform Act of 1978, as amended, states, among other things, that federal personnel management should be free from prohibited personnel practices (PPP)  The law also authorizes the OSC to investigate allegations involving PPP that include reprisals against employees for the lawful disclosure of certain information pertaining to individuals who engage in such conduct or other wrongdoing  According to Standards for Internal Control in the Federal Government, laws and regulations may require entities to establish separate lines of communication, such as whistle-blower and ethics hotlines, for communicating confidential information  Management informs employees of these separate reporting lines, how they operate, and how they are used, and how the information will remain confidential  Reporting lines are defined at all levels of the organization and provide methods of communication that can flow down, across, up, and around the structure  Our interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring  Whistle-blowers we spoke to alleged that managers in their chain of command took a number of actions that were not traceable to retaliate against the whistle-blowers after they reported misconduct  These alleged actions included being reassigned to other duty locations or denied access to computer equipment necessary to complete assignments, and socially isolating these individuals from their peers, among other things  Whistle-blowers we spoke to also expressed concerns regarding the lack of guidance available to employees about how to file a disclosure through VA and the OSC  Whistle-blowers stated that employees are not provided adequate information on how to document or file a claim of misconduct or retaliation  Employees can file disclosures regarding misconduct and complaints of retaliation through multiple reporting lines  As mentioned previously, however, the OSC will generally not refer to the Secretary under its statutory process a disclosure if the OIG has conducted or is already conducting an investigation of that particular complaint  Thus, whistle-blowers may limit their chance of having an independent, non-VA entity oversee their complaint if they file a complaint with the OIG first  The Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017 requires the Secretary, in coordination with the Whistleblower Protection Ombudsman, to provide training regarding whistle-blower disclosures to each employee of VA  This information shall include, among other items, an explanation of each method established by law in which an employee may file a whistle-blower disclosure, an explanation that the employee may not be prosecuted or reprisal taken against him or her for disclosing information, and language that is required to be included in all nondisclosure policies, forms, and agreements  The Secretary shall also publish a website and display the rights of an employee making a whistle-blower disclosure  In August 2017, VA began providing additional information on its website for potential whistle-blowers who wish to report criminal or other activity to the OIG  The information provided focuses on reporting misconduct to the OIG and provides other lines of reporting established by law in which an employee may file a whistle-blower disclosure, such as directly to an immediate supervisor or the OSC  In addition, the information provided explains the process after misconduct is reported through the OIG Hotline, but does not clarify the process for referred disclosure cases received from the OSC  As mentioned previously, OIG officials stated that a disclosure made to the OSC or the OIG can be referred back to the facility or program office where the allegation originated, which may compromise confidentiality  Consequently, employees may not be aware that their information may be shared among the OSC, the OIG, OAWP, or VA facility and program offices when a disclosure is made to the OSC  Adequately communicating the investigative process to employees may alter their decision to report wrongdoing  Without a clear understanding of the lines for reporting misconduct and how they operate, whistle-blowers may be uncertain as to their options for reporting misconduct, which increases the risk that they may not report workplace misconduct  According to OSC, it has learned through its cases that OAWP has a practice of allowing VA employees, who are the subject of the allegations brought forward by whistle-blowers to review or participate in investigations, or both, which could make the whistle-blower feel uncomfortable or intimidated  This practice has led to confusion regarding the role and responsibilities of OAWP personnel  OAWP’s use of VA employees that are employed at the facility under investigation in the review of allegations creates the possibility of a conflict of interest or an appearance of a conflict of interest  For example, in a case OSC described in its comments on a draft of our report, an OAWP representative who was also associated with the human-resource office at the VISN that oversees the whistle-blower’s facility, placed the whistle- blower under oath and questioned her about issues unrelated to the referred allegations  OSC has since sought clarification of OAWP’s role and the OAWP employee’s possible connection to the VISN  While VA collects data on some types of disciplinary actions, it is limited in its ability to use those data because it does not collect all misconduct and associated disciplinary-action data through a single information system, or multiple interoperable systems  Absent a process to collect such data department-wide, VA does not have the ability to analyze and report data systematically  In addition, the data currently collected are not always reliable or useful  The inclusion of appropriate documented guidance and standardized field definitions would help to ensure VA collects reliable misconduct and associated disciplinary-action data  With high-quality information that is accurate and comprehensive, VA management would be better positioned to make knowledgeable decisions regarding the extent of misconduct occurring and how it was addressed, department-wide  VA has not ensured that program and facility human-resources personnel adhere to policy governing documentation contained within evidence files to support conclusions reached  In addition, VA often had no record of the evidence involved with the adjudication of these actions and could not verify whether these individuals received reasonable and fair due process  The absence of documentation in some files also raises the possibility that VA may not always be in compliance with its procedures for governing the adjudication of alleged employee misconduct  Additionally, ensuring that human-resources personnel adequately inform employees of their rights during the adjudication process would provide them with a reasonable opportunity to present their case when preparing their defense  VA also does not consistently adhere to OPM and NARA guidance in defining a specific retention period for adverse action files  This results in an inconsistent retention of these files across VA which complicates department-wide analysis  VA’s inconsistent adherence to the standards provided by the OIG to facilities and program offices for investigating and resolving misconduct cases increases the risk that misconduct case are not being handled appropriately  Additionally, the lack of verification of responses received to ensure documentation supports findings and recommendations has contributed to evidence that does not always meet the requirements outlined by the OIG  Finally, timely responses are not consistently provided when facility and program offices report findings to the OIG’s Hotline Division  OAR did not monitor whether substantiated instances of misconduct involving senior officials received disciplinary action  OAR’s Legacy Referral Tracking List also did not accurately reflect the disciplinary action that was decided based on the results of the investigation  When disciplinary actions are taken, in response to findings of misconduct, but are not entered within an appropriate information system, or are inaccurately recorded, it is more difficult to monitor whether disciplinary actions have been implemented in substantiated instances of misconduct involving senior officials  As demonstrated, this may result in no action being taken for substantiated misconduct or the previous penalties not having the corrective effect for repeat offenders  There is also an increased risk that substantiated misconduct will go unaddressed if there is no recommendation for corrective action  Further, VA also does not have internal controls to ensure adherence to proper separation-of-duty standards involving the removal of an employee  Such controls would minimize the risk of abuse when officials act as both proposing and deciding officials  In addition, VA does not have oversight measures to ensure that all allegations of misconduct referred by the OIG to facility and program offices are investigated by an entity outside the control of the facility or program office involved in the misconduct  The investigation of allegations of misconduct by the program office or facility where the complaint originated may present the appearance of a conflict of interest in which managers and staff at facilities may investigate themselves or other allegations where they may have a personal stake or bias in the matter to be investigated  Therefore, the risk that the results of the investigation are minimized, or not handled adequately, is increased  VA’s newly developed process to communicate the scope of its reviews that involve matters referred by the OSC to the Office of the Secretary will be important to ensure any allegations outside the purview of the OIG’s investigation are fully addressed by a departmental entity in accordance with OSC requirements  Further, the OIG’s inability to locate investigative documentation prevents a third party from verifying whether the OIG examined the disclosures, whether any recommendations were addressed, or whether appropriate disciplinary action was taken for these cases  This lack of information has direct influence on management’s ability to make sound decisions relating to investigative matters  According to OIG officials, a spreadsheet is being used for tracking case numbers associated with disclosures, but plans to implement a process within the new system  Nonanonymous whistle-blowers faced higher rates of adverse action subsequent to their disclosure than the VA population as a whole  In addition, these individuals also had attrition rates higher than their peers who had not filed a disclosure  The disparities between whistle-blowers and other employees may be an indication that retaliation by senior officials may have occurred after misconduct was disclosed  Although VA has started to provide additional information for potential whistle-blowers who wish to report criminal or other activity to the OIG, VA does not have a process to inform employees of how their information may be shared between organizations when misconduct is reported  Without a clear understanding of how the lines for reporting misconduct operate, whistle- blowers may be uncertain as to their options for reporting misconduct, increasing the risk that they may not report workplace misconduct  We are making the following 16 recommendations to VA  The Secretary of Veterans Affairs should develop and implement guidance to collect complete and reliable misconduct and associated disciplinary-action data department-wide, whether through a single information system, or multiple interoperable systems  Such guidance should include direction and procedures on addressing blank data fields, lack of personnel identifiers, and standardization among fields, and on accessibility  (Recommendation 1) The Secretary of Veterans Affairs should direct applicable facility and program offices to adhere to VA’s policies regarding employee misconduct adjudication documentation  (Recommendation 2) The Secretary of Veterans Affairs should direct the Office of Human Resource Management (OHRM) to routinely assess the extent to which misconduct-related files and documents are retained consistently with VA’s applicable documentation requirements  (Recommendation 3) The Secretary of Veterans Affairs should direct OHRM to assess whether human-resources personnel adhere to basic principles outlined in VA Handbook 5021 when informing employees of their rights during the adjudication process for alleged misconduct  (Recommendation 4) The Secretary of Veterans Affairs should adhere to OPM and NARA guidance and establish a specific record-retention period for adverse action files  In doing so, the Secretary should direct applicable administration, facility, and program offices that have developed their own record-retention schedules to then adhere to the newly established record-retention period  (Recommendation 5) The Department of Veterans Affairs (VA) Inspector General should revise its policy to include a requirement to verify whether evidence produced in senior-official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  (Recommendation 6) The Secretary of Veterans Affairs should direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  (Recommendation 7) The Secretary of Veterans Affairs should direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented for all substantiated misconduct by senior officials  (Recommendation 8) The Secretary of Veterans Affairs should direct OAWP to develop a process to ensure disciplinary actions proposed in response to findings of misconduct are recorded within appropriate information systems to maintain their relevance and value to management for making decisions and take steps to monitor whether the disciplinary actions are implemented  (Recommendation 9) The Secretary of Veterans Affairs should direct OAWP to issue written guidance on how OAWP will review the disposition of accountability actions for all substantiated misconduct cases involving senior officials resulting from investigations  (Recommendation 10) The Secretary of Veterans Affairs should implement internal controls to ensure that proper adherence to separation-of-duty standards involving the removal of an employee are consistent with policy  (Recommendation 11) The Secretary of Veterans Affairs should develop oversight measures to ensure all investigations referred to facility and program offices are consistent with policy and reviewed by an official independent of and at least one level above the individual involved in the allegation  To ensure independence, referred allegations of misconduct should be investigated by an entity outside the control of the facility or program office involved in the misconduct  (Recommendation 12) The VA Inspector General, in consultation with the Assistant Secretary of OAWP, should develop a process to ensure that OSC case numbers are linked to the investigative case number and final report  (Recommendation 13) The Secretary of Veterans Affairs should direct OAWP to develop a time frame for the completion of published guidance that would develop an internal process to monitor cases referred to facility and program offices  (Recommendation 14) The Secretary of Veterans Affairs should ensure that employees who report wrongdoing are treated fairly and protected against retaliation  (Recommendation 15) The Secretary of Veterans Affairs should direct OAWP to develop a process to inform employees of how reporting lines operate, how they are used, and how the information may be shared between the OSC, the OIG, OAWP, or VA facility and program offices when misconduct is reported  (Recommendation 16) We provided a draft of this report to the Department of Veterans Affairs (VA), VA Office of Inspector General (OIG), and the Office of Special Counsel (OSC) for review and comment  In its comments, VA concurred with nine of our recommendations and partially concurred with five (see app  VI for a copy of VA’s letter)  Regarding our recommendations to the Inspector General, the OIG concurred with one recommendation and partially concurred with the other  The OIG also provided comments on our findings (see app  VII for a copy of the OIG’s letter)  We received technical comments by e-mail from OSC’s Principal Deputy Special Counsel, which we incorporated in the report as appropriate  Regarding VA’s comments, in its response to our first recommendation that the Secretary develop and implement guidance to collect complete and reliable misconduct and associated disciplinary-action data department-wide, VA concurred and outlined steps it plans to take to address our recommendations  These steps include the creation of new policies to address blank data fields, lack of personnel identifiers, lack of standardization among fields, and accessibility issues related to misconduct and associated disciplinary-action data department-wide  The target date for system implementation, dependent on approved funding and acquisition-related requirements, is January 1, 2020  On our second recommendation, that the Secretary direct applicable facility and program offices to adhere to VA’s policies regarding employee-misconduct adjudication documentation, VA concurred  It stated that a memorandum will be distributed to reiterate facility and program-office requirements to adhere to VA Handbook 5021, Employee/Management Relations, no later than October 1, 2018  VA also concurred with our third recommendation, that the Secretary direct the Office of Human Resource Management (OHRM) to routinely assess the extent to which misconduct-related files and documents are retained  According to VA, OHRM will assess, during periodic Oversight and Effectiveness Service reviews, the extent to which misconduct- related files and documents are retained  The first assessment is to be incorporated into the fiscal year 2019 Oversight and Effectiveness Service schedule no later than November 1, 2018  VA concurred with our fourth recommendation, that the Secretary direct OHRM to assess whether human-resources personnel adhere to basic principles outlined in VA Handbook 5021  VA stated that OHRM will assess, during periodic Oversight and Effectiveness Service reviews, whether human-resources and administration personnel adhere to basic principles outlined in VA Handbook 5021  The first assessment is to be incorporated into the fiscal year 2019 Oversight and Effectiveness schedule no later than November 1, 2018  In its response to our fifth recommendation, that the Secretary adhere to Office of Personnel Management (OPM) and National Archives and Records Administration (NARA) guidance and establish a specific record- retention period for adverse-action files, VA concurred and indicated that the Human Resources and Administration Assistant Secretary will establish VA guidance regarding the retention period for adverse-action files  In addition, the Human Resources and Administration Assistant Secretary is to advise applicable administration, facility, and program offices that have developed their own record-retention schedules to adhere to the newly established directive  According to VA, the directive will be established no later than November 1, 2018  VA partially concurred with our seventh recommendation, that the Secretary direct departmental heads to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  VA stated that the process described in our report pertaining to OIG findings or results will be changed to require all such reports to be submitted to OAWP  VA also indicated that it expects to publish new guidance by October 1, 2018, that will require the Office of Accountability and Whistleblower Protection (OAWP) to review responses and recommendations from facilities or program offices  Given VA’s comments, we have revised our draft recommendation to have the Secretary direct OAWP, not the department heads, to ensure evidence demonstrates that the six elements have been addressed  VA also partially concurred with our eighth recommendation, that the Assistant Secretary of OAWP review all substantiated misconduct by senior officials to verify whether disciplinary action has been implemented  VA stated that all substantiated misconduct by senior leaders in VA is handled by OAWP from intake, through investigation, working with the proposing and deciding officials  VA also stated that it expects to publish written guidance by October 1, 2018, that will clarify how OAWP will work with the appropriate servicing personnel office to ensure that the recommended disciplinary actions decided are implemented for substantiated misconduct involving senior officials  Given VA’s comments, we have revised our draft recommendation to have the Secretary of Veterans Affairs direct OAWP to issue written guidance on how OAWP will verify that appropriate disciplinary action has been implemented for all substantiated misconduct by senior officials  VA partially concurred with our ninth recommendation, that the Assistant Secretary of OAWP develop a process to ensure disciplinary actions proposed are recorded within appropriate information systems  VA stated that the VA-wide discipline tracking system currently used by OAWP will eventually be phased out  It added that once the Human Resources Information System (HRSmart) is capable of capturing and recording similar data, it will be used for this purpose  Accordingly, we have not revised our draft recommendation  VA partially concurred with our 10th recommendation, that the Assistant Secretary of OAWP assess all misconduct cases involving senior officials to ensure investigative reports with findings of substantiated misconduct include recommendations for action  According to VA, OAWP has instituted several processes since our review  VA plans to issue written guidance that outlines the process for the review and disposition of appropriate accountability actions for allegations of misconduct by senior officials by October 1, 2018  Given VA’s comments, we have revised our draft recommendation to have the Secretary of Veterans Affairs direct OAWP to issue written guidance on how OAWP will review the disposition of accountability actions for all substantiated misconduct cases involving senior officials resulting from investigations  In its response to our 11th recommendation, that the Secretary implement internal controls to ensure that separation-of-duty standards involving the removal of an employee are consistent with policy, VA concurred  It stated that it will also establish and distribute internal controls to ensure that separation-of-duty standards involving the removal of an employee are consistent with policy no later than November 1, 2018  VA partially concurred with our 12th recommendation, that the Secretary take steps to ensure independence of referred allegations of misconduct by requiring that investigations be conducted outside the control of the facility or program office involved in the misconduct  VA stated that OAWP is responsible for recording, tracking, reviewing, and confirming the implementation of recommendations from audits and investigations  However, VA did not address how it will ensure the independence of the entity responsible for conducting an investigation  As we discuss in our report, during the review OAWP officials stated that the process of referring cases of misconduct back to facilities and program offices where the misconduct occurred will continue  Accordingly, we have not revised our draft recommendation and believe implementation of it will help ensure independence  VA concurred with our 14th recommendation, that the Assistant Secretary of OAWP develop a time frame for the completion of published guidance for the development of an internal process to monitor cases referred to facility and program offices  VA provided an expected date of October 1, 2018, for publishing the internal VA guidance, with the subsequent Directive and Handbook to be published as rapidly as staff coordination permits  In its response to our 15th recommendation, that the Secretary ensure that employees who report wrongdoing are treated fairly and protected against retaliation, VA concurred  It stated that OAWP and OSC have developed a functional process to ensure whistle-blower protections are implemented, but did not indicate what the process entails  The VA Secretary has also delegated authority to the Executive Director, OAWP, to put individual personnel actions on hold if the actions appear motivated by whistle-blower retaliation  VA added that OAWP has also hired two whistle-blower program specialists specifically to increase awareness of whistle-blower protections and work with individuals that disclose employee wrongdoing to ensure individuals are treated fairly and protected from retaliation for their disclosures  VA concurred with our 16th recommendation, that the Assistant Secretary of OAWP develop a process to inform employees of how reporting lines operate  VA stated that it will provide whistle-blower training to all employees on a biennial basis, which will include the reporting lines for disclosures of wrongdoing, the manner in which disclosures flow once they are made, how information is shared among the whistle-blower entities, and what protections exists for those who disclose wrongdoing  Regarding our recommendations to the Inspector General, the OIG partially concurred with our sixth recommendation, to revise its policy to include a requirement to verify whether evidence produced in senior- official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  The OIG indicated that VA Directive 0701 is currently being updated to require a written or electronic signature from the person preparing the responses as an attestation that the specific requirements of the directive were met  The OIG also indicated in its letter that the OIG’s Hotline staff carefully review the case response but Hotline staff are not required to request an updated response from VA to address matters not necessary to the resolution to the referral  The OIG asserted that requesting an update would detract from the resources for other important VA activities  On page 4 of the OIG’s letter, the OIG states that Hotline analysts are allowed to exercise some discretion in accepting responses that may include minor departures from the six elements  We continue to believe that, in order to have a complete response to a referral, all six elements required by the directive should be addressed  In addition, Directive 0701 does not allow for the use of professional judgement to decide which elements to include or not to include in a response  While we agree that requiring a written or electronic signature from the person preparing the responses as an attestation will help ensure that the specific requirements of the directive were met, we maintain that not requiring Hotline analysts to review responses to ensure that all elements of the directive are addressed is inconsistent with the intent of the directive  In its response to our 13th recommendation, that the OIG develop a process to ensure that an OSC case number is linked to the investigative case number and the final report, the OIG concurred  It stated that it will engage with the Executive Director of OAWP to develop a process to ensure that OSC case numbers are linked to OIG and OAWP investigative case numbers, as appropriate, and linked to any final report of investigation  In addition to its response to recommendations, the VA OIG also raised a number of concerns with our findings  Page 1 of its letter summarizes some of these concerns and then provides more detail on each concern raised, starting on page 2  Our responses to each of these detailed concerns are provided below  The OIG stated that our report does not focus on the most important cases, but focuses primarily on case referrals regarding senior officials that were not handled by the OIG because the allegations were lower risk or because of resource constraints  In addition, the OIG stated that GAO risks presenting a skewed picture of the OIG’s oversight work  We disagree with this characterization of our findings  We requested that the OIG provide us with data from the OIG’s Master Case Index (MCI) information system that would allow us to select a sample of cases, in accordance with the scope of our review  The OIG was unable to provide the requested information due to several reasons  Instead, the OIG provided data from the OIG Hotline and Office of Investigations case- management systems (subsystems within MCI) that contained a limited number of fields for analysis and 23 cases pertaining to SES misconduct that were referred to VA for investigation during GAO’s period of review  Therefore, as we discuss in the report, we were only able to review the 23 senior-official misconduct cases included in our report because the OIG was only able to provide related documentation for these cases  The OIG stated that we only reviewed a sample of just 23 case referrals from fiscal years 2011 through 2014  As described, we reviewed all 23 senior-official misconduct cases that were referred to VA for investigation that the OIG was able to provide us, not a sample  The OIG stated that our report inaccurately states that the extracts received from the MCI information system contained missing information  We disagree with this characterization of our findings  Our review included a comprehensive assessment of the reliability of the OIG’s data  To conduct this assessment, we requested an explanation of each data field to clarify when fields are normally populated and how they are used  Our findings are consistent with the information provided in response to this request  For example, the OIG’s response to our data-reliability assessment stated that the data field used to identify the type of allegations being investigated should never be blank  However, we found that field to be blank in some cases in the data that were provided to us, though the OIG asserted that the MCI information system is a relational database where each case may be associated with multiple allegations and codes  In response to the OIG’s comments on our report, we requested supporting documentation to demonstrate that the fields analyzed during our period of review did not contain missing data  The OIG provided the MCI information system user’s manual that contains detailed procedures for accessing and entering data into the MCI information system, and a compilation of various internal documents  However, the documentation did not provide evidence of the completeness of data entered into the MCI information system as part of quality-assurance reviews performed by the OIG or other designated entity  Absent evidence of data-quality reviews aimed at assessing the accuracy and completeness of data contained in the MCI information system, we did not change the conclusions based on our previous analysis  The OIG stated that our report provides incomplete information regarding sampled cases and mischaracterized one of the OIG’s case referrals in the body of the report  We disagree with this characterization of our findings  Specifically, the OIG said that we inaccurately stated that a medical center director conducted the investigation into his own alleged misconduct and found no allegations were substantiated  The synopsis included in our report clearly articulates that the medical center director was named in the allegation for having received a similar complaint involving time and attendance abuse by a physician  The medical center director, who provided the response to the OIG, was implicated in the allegation as having not addressed a similar time and attendance complaint regarding the same physician 2 years earlier  The OIG did not provide any supporting documentation to demonstrate that the alleged time and attendance abuse allegations against the physician were not substantiated  The OIG stated that our report inaccurately stated that the medical center director conducted his own investigation of himself and found no allegations were substantiated  We disagree  In response to the OIG’s comments on our report, we requested that the OIG provide additional support used to determine that the medical center director did not investigate the allegation in which he was named  The additional case documentation provided by the OIG further reaffirmed our assessment that the medical center director performed his own investigation and found no allegations were substantiated  Additional documentation provided by the OIG indicated that the OIG referred the case to the Veterans Integrated Service Network (VISN) for a response  However, documentation we examined during the course of our audit, and the documentation provided in response to our draft report, indicates that the medical center director performed the investigation of the allegations and then the results were routed through the VISN back to the OIG  The OIG stated that routing the response through the VISN should address our concerns of independence  This process does not address our concerns regarding independence because VA Directive 0701 states that all responses to Hotline case referrals must contain evidence of an independent review by an official separate from and at a higher grade than the subject / alleged wrongdoer  In this case, the name of the medical center director who signed the facility response provided to the OIG was the same individual named in the allegations  The OIG stated that the report does not provide a balanced presentation of the rigor with which the OIG reviews all incoming Hotline contacts and case responses  We disagree with this characterization of our findings  As described above, the OIG was unable to provide comprehensive data to select a sample of OIG audits, evaluations, and inspections for review due to the limitations cited  We focused on misconduct involving senior officials consistently with the scope of our review and thoroughly reviewed all 23 senior-official misconduct cases that were referred to VA for investigation, which were the only cases that the OIG was able to provide  The OIG stated that the description for one of the cases included in appendix V of the draft report was incomplete because we misunderstood the OIG’s process  We disagree with this characterization  In response to the OIG’s comments on our report, we requested additional supporting documentation  The documentation provided reaffirmed our assessment that another medical center director performed his own investigation and found no allegations were substantiated  Similar to the case described above, the medical center director completed his own investigation and then routed the response through the VISN back to the OIG  In contrast to the previous case, however, the Hotline Workgroup reviewed the response to the OIG and found it to be insufficient  Specifically, the OIG noted that the medical center director who provided the response was the subject of the complaint, despite the response being directed to the VISN, and requested clarification  The VISN informed the OIG that it is not its policy for the complainant to have any involvement in the review and data submission on a case in which the complainant is involved  The VISN stated that while this did obviously occur in this instance, it has taken steps to ensure it does not occur in the future  The supporting evidence provided for the case included in appendix V also contradicts the OIG’s previous assertion that the routing of a response through the entity with oversight (VISN) over the medical center director should have addressed GAO’s concerns of independence  The OIG stated our report provides a misrepresentation of the OIG’s failure to follow internal policies for department responses  We disagree  According to OIG statements on page 4 of the OIG’s letter, Hotline analysts are allowed to exercise some discretion in accepting responses that may include minor departures from the six elements required in VA Directive 0701  We continue to believe that in order to have a complete response to a referral, all six elements required by the directive should be addressed  On the basis of our review, the OIG does not have an effective method to ensure that cases referred to VA are reviewed in accordance with VA Directive 0701  Out of the 23 cases we reviewed, only 4 included sufficient documentation needed to support VA’s findings, and we could not identify a case that contained all six elements required in VA Directive 0701  This suggests that the current OIG review process is not adequately resolving case referrals, as asserted by the OIG’s response  In addition, VA Directive 0701 does not currently include a provision that would allow Hotline analysts to deviate from the six required elements  As stated in our report, the OSC also raised concerns regarding 40 percent of disclosure cases that were referred to VA facility and program offices  The OIG stated that much of the information in the draft report is dated and ignores system updates, specifically several key Hotline-related process improvements since 2014  Although our review began in 2015, we disagree with this characterization of our findings  In our report, we included relevant improvements to demonstrate where the OIG was able to provide support for those improvements  For example, our report discusses: (1) a new process for communicating the scope of reviews that involve matters referred by the OSC to the Office of the Secretary, (2) a description on the VA website of the process for employees who wish to report criminal or other activity to the OIG, (3) a new Enterprise Management System, and (4) a new process for receiving whistle-blower disclosures by the Secretary  In response to the OIG’s comments on our report, we requested additional documentation for any systems, practices, or personnel changes that have been implemented since 2011, including improvements to Hotline-related processes since 2014 that were not included in our report  In response, the OIG provided a copy of the OIG’s organizational chart (current as of Apr  23, 2018), described the oversight responsibilities of each OIG component, and summarized the pertinent staff positions within each component  On the basis of this documentation, we identified a new office (the Office of Special Reviews), a promotion, staff reassignments, and numerous vacancies during our review period  However, the OIG did not provide evidence of any measures to improve the MCI information system, case-referral processes, or relevant staff roles that were not already included in our report  As described above, the OIG was unable to provide comprehensive data to select a sample of OIG audits, evaluations, and inspections for our initial review due to the limitations cited  In response to the OIG’s comments on our report, we requested documentation related to any significant changes that have been made to the MCI information system that allows the OIG to identify all allegations of misconduct for export and analysis  The OIG provided additional information regarding overall departmental achievements that are highlighted in the OIG’s Semiannual Report to Congress, and other products from its website published between fiscal years 2011 through 2018  We recognize the OIG’s broader administrative and oversight work described in the published reports  However, this information does not address changes specifically made to the MCI information system that would enable the OIG to analyze cases pertaining to alleged misconduct by senior officials that we requested  We are sending copies of this report to the appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-5045 or larink@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  Our objectives were to determine the extent to which the Department of Veterans Affairs (VA) (1) collects reliable information associated with employee misconduct and disciplinary actions that is accessible and could be used to analyze misconduct department-wide; (2) retains documentation that demonstrates VA adheres to its policies when adjudicating cases of employee misconduct; (3) ensures allegations of misconduct involving senior officials are reviewed in accordance with VA investigative standards, and these officials are held accountable; (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA  For the first objective, we obtained VA employee misconduct data from 12 information systems operated by various VA components covering October 2009 through July 2017, where available  To determine the reliability of VA’s misconduct data, we analyzed the contents of the 12 information systems operated by various offices across VA  These data encompass each of the three major administrations that constitute VA— the National Cemetery Administration (NCA), Veterans Benefits Administration (VBA), and Veterans Health Administration (VHA)  We selected the information systems based on our discussions with VA officials and staff that oversee the data and, hence, identified databases capable of collecting information pertaining to either employee misconduct or disciplinary actions  Data fields were selected based on whether they would provide beneficial information to better understand the disciplinary process  VA’s Personnel and Accounting Integrated Data (PAID) system, which was developed to track payroll actions, contains information about adverse disciplinary actions that affect employee salary department-wide  We obtained an extract of all adverse disciplinary actions from the PAID system  We assessed the reliability of each system for the purposes of identifying and tracking misconduct cases  To do this, we performed electronic tests on 12 information systems to determine the completeness and accuracy of the fields contained in the data files  We also submitted to the overseeing offices for all 12 information systems general data-quality questions regarding the purpose of the data, their structure, definitions and values for certain fields, automated and manual data-quality checks to ensure the accuracy of the data, and limitations  As discussed further, the data were generally not reliable for a department-wide assessment of all misconduct and disciplinary actions due to the lack of completeness and compatibility of the data across all information systems  VA staff could not confirm whether some of the missing data we identified were artifacts of the database extraction process VA used to assemble the data files we used in our review  Despite challenges with aspects of the data, we found the data sufficiently reliable for conducting analysis where fields were populated and field definition concurrence was obtained by program offices  For the second objective, we selected a generalizable stratified random sample of 544 misconduct cases from October 2009 through May 2015  Where available, we reviewed the employees’ disciplinary-action files and Electronic Official Personnel Folders to determine the extent to which VA’s actions were consistent with disciplinary policy outlined in VA Handbook 5021, Employee/Management Relations  These data encompass each of the three major administrations that constitute VA— NCA, VBA, and VHA  We determined the data to be sufficiently reliable for analysis of disciplinary actions affecting salary that resulted from misconduct that was not reported to supervisors directly from employees  Accordingly, our sample only includes misconduct cases that resulted in a change in salary or were reported to departmental organizations within the 12 information systems selected  We developed a data-collection instrument to document the results of our case reviews  We revised our data-collection instrument to address issues found during the course of our analysis, and developed a companion document that outlined the decision rules for reviewing cases  We also designated two primary reviewers to ensure the decision rules were consistently applied across all cases  Our review of laws and regulations revealed that disciplinary rules sometimes vary depending on whether employees fall under Title 5, Title 38, or hybrid Title 5 and Title 38 hiring authority  To minimize confusion associated with these differences, we incorporated criteria into our data- collection instrument  In addition, we were unable to obtain complete case information for 25 percent of the cases  For these cases, we obtained direct access to the Office of Personnel Management’s (OPM) Electronic Official Personnel Folders system to attempt to recover some of the missing information  Ultimately, we were unable to complete our review for 10 percent of cases in our sample because of missing files  In addition to reporting missing case information, we used our generalizable analysis results to project VA-wide figures for several data elements that were not in compliance with VA policy  Unless otherwise noted, estimates in this report have a margin of error of +/-7 4 percentage points or less for a 95 percent confidence interval  For the third objective, we analyzed data from the Office of Accountability Review (OAR) Legacy Referral Tracking List and VA Office of Inspector General (OIG) case-referral and investigative case-management systems, and we selected cases for in-depth review  We selected these two systems based on discussions with VA officials who were knowledgeable with databases that have the capacity to track misconduct information pertaining to senior officials  The OAR Legacy Referral Tracking List comprises referrals from January 2011 through May 2015  The OIG provided 23 case-referral files involving senior officials from calendar years 2011 through 2014  As part of our review of the OIG case files, we evaluated specific data elements contained in VA’s response documents using VA policy for referring and reviewing misconduct cases  We assessed the reliability of the OAR Legacy Referral Tracking List and OIG case-management systems for the purposes of identifying and tracking misconduct cases  To do this, we performed electronic tests on each database to determine the completeness and accuracy of the fields contained in the data files, including senior-official indicators  Where feasible, we opted to match individual datasets to PAID to determine whether disciplinary actions were administered as prescribed  We also submitted to OAR and the OIG general data-quality questions regarding the purpose of the data, their structure, definitions and values for certain fields, automated and manual data-quality checks to ensure the accuracy of the data, and limitations  On the basis of this information, we found the OAR data to be sufficiently reliable for conducting analysis where fields were sufficiently populated  For the OAR data, we matched the persons of interest to adverse-action files from PAID to determine whether adverse disciplinary actions were administered as prescribed during the available time frame (January 2011 through May 2015)  We also obtained VA’s response documents for the 23 case-referral files provided by the OIG to evaluate whether VA was adhering to its own policy for referring and reviewing misconduct cases  Through our OAR Legacy Referral Tracking List analysis, we identified illustrative case examples of misconduct involving senior officials  Further, based on our evaluation of the 23 OIG case referrals using VA’s referral policy, we developed several illustrative case examples  For the fourth objective, we interviewed senior officials from VA and the OSC responsible for investigating whistle-blower complaints  We obtained the OSC’s procedures for referring disclosure complaints and VA’s policy for investigating these complaints once received at the agency  In addition, we obtained whistle-blower disclosure data from the Office of Special Counsel (OSC) covering calendar years 2010 through 2014  To determine the reliability of the data, we conducted electronic testing and traced data elements to source documentation  We determined the data to be sufficiently reliable to identify the total number of cases that were investigated by the OIG, or referred to facility and program offices  We also observed a course to assess VA’s training provided to VA employees conducting investigations  We identified 135 OSC disclosure cases for analysis based on two criteria: (1) they contained at least partial complainant information (i e , the allegations were not anonymously reported or could be identified with supplemental information) and (2) they contained an indicator that the case had been closed by the OSC pending an ongoing investigation by VA or the OIG  These cases represent the universe of VA disclosures accepted by the OSC  Of the 135 disclosure cases referred to VA, 53 cases were referred to VA facility and program offices for further investigation  The remaining 82 disclosure cases indicated that they were investigated by the OIG  We reviewed the results of OSC’s assessment of investigative documentation developed by VA for these whistle-blower disclosure cases  For the fifth objective, we analyzed the 135 whistle-blower disclosure cases obtained from the OSC  These cases represent the universe of VA disclosures accepted by the OSC from calendar years 2010 through 2014, which were investigated by VA  We obtained an extract of year-end rosters from the PAID system as of September for fiscal years 2010 through 2014, with a final extract through May 30, 2015  Finally, we interviewed representatives from whistle-blower advocacy groups, as well as established whistle-blowers who disclosed wrongdoing or retaliation at VA and who were referred to us by one advocacy group  Of the 135 disclosures received by the OSC, a total of 129 employees made a total of 130 disclosures nonanonymously  For these 130 disclosure cases, we reviewed OSC and OIG investigative reports, as well as PAID roster files, to gather additional information to perform analysis of potential retaliation  We also interviewed six individual whistle- blowers with formal disclosure cases accepted by the OSC, indicating that the OSC had previously reviewed the case and determined that it contained sufficient evidence and merit to warrant further investigation  Our analysis of potential retaliation comprised two parts  First, we compared the 129 employees associated with the selected OSC cases to the PAID rosters using the complainants’ information to determine whether employees associated with the selected OSC cases were more likely to leave the agency  We identified the overall count and proportion (across years) of roster-matched employees who made a disclosure between fiscal years 2010 through 2014 but were not employed at VA the following fiscal year  Second, to determine whether employees associated with the selected OSC cases were more likely to receive disciplinary action, we also calculated the yearly totals and proportion of roster-matched employees identified above for whom a record existed in the PAID disciplinary action information system  We did this by comparing the proportion of employees who received one or more disciplinary actions in the year prior to the appearance in the roster, in the same fiscal year as the roster, and in the subsequent fiscal year  We also completed this analysis utilizing the PAID roster file to determine the yearly proportion of all VA employees who left the agency  On the basis of the results of our analysis, we reported by fiscal year the percentage of whistle-blowers that received disciplinary action or left VA at a higher rate than the overall VA population following a disclosure  To address all objectives, we interviewed senior officials from VA’s major components responsible for investigating and adjudicating cases of employee misconduct  We also reviewed standard operating procedures, policy statements, and guidance for staff charged with investigating and adjudicating allegations of employee misconduct  We conducted this performance audit from January 2015 to May 2018 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  This data file is designed to track referrals made to OAR, including allegations of misconduct related to senior officials  Through our analysis of this spreadsheet, we identified 11 fields out of 92 that were missing information that could be used to analyze misconduct  Complainant #1 (First Name) (20 percent of 1,245 blank)— According to OAR, this field is populated when there is a known complainant for a matter  Some matters referred to OAR may be anonymously disclosed and not contain complainant information  This file also contains a case-origin field that specifies whether a case was anonymous  Our review of both the complainant and case-origin field indicated that only 11 percent of the complaints were generated from an anonymous source, and the remaining records should have included a complainant name  Disciplinary Action (96 percent of 1,245 blank)—This field should be populated to indicate whether a disciplinary action was taken after the completion of an investigation  Grade (97 percent of 1,245 blank)—According to OAR, this field should be populated with the grade of the Person of Interest (POI), if known  Our review of this field indicated that 97 percent were blank, therefore we were unable to analyze the variation in grade level for officials who were the subject of complaints  OAR Action (77 percent of 1,245 blank)—According to OAR, this field should be populated as an internal reference to describe what stage in the administrative process the matter was in when received  The lack of information did not allow for analysis of the types of actions taken for each case  Person of Interest (POI) (47 percent of 1,245 blank)—This field specifies the first and last name of the Department of Veterans Affairs (VA) employee who is the subject of an allegation  POI (Person of Interest) Last Name 1–5 (51 to 99 percent of 1,245 blank)—This field specifies the last name of VA employee who is the subject of an allegation  There are a total of five person-of-interest (POI) fields for each matter  According to OAR, blank POI fields occur when the case has fewer than five POIs or the POI was not specified in the matter referred  Our review of the five POI fields indicated that more than half of the records did not contain at least one POI because no individual was specified  The lack of information did not allow for further investigation of senior-level officials involved in misconduct  Proposed Action (97 percent of 1,245 blank)—According to OAR, this field should be populated to notify OAR staff if any disciplinary action was proposed  Our review of this field indicated that 97 percent were blank, suggesting that very few high-level officials received corrective action, or the field was not consistently completed for each record  Due to the large share of blank values, the data posed limitations when analyzing how many senior officials received corrective action as a result of a complaint  This data file is designed to track misconduct and disciplinary actions taken against VA employees  Through our analysis of this spreadsheet, we identified 9 fields out of 21 that were missing information that could be used to analyze misconduct  Action Taken (3 percent of 9,851 blank)—According to OAR, this field should be populated with the action that the deciding official takes, with the exception of pending actions  If there is a pending action, this field will remain blank  Our review of the action-taken field found three records that were annotated as a “pending decision” within this field, which indicates that there is an option for entering information into this field when there is an action pending and the field should never be blank  Admin Leave (30 percent of 9,851 blank)—According to OAR, this field should be populated if an employee is placed on administrative leave while an adverse action is pending  If an employee is not placed on administrative leave, the field may be left blank  Our review of the admin-leave field found that about 66 percent of the records were annotated as “no” within this field, which indicates that there is an option for entering information into this field when an employee was not placed on administrative leave  Date Proposed (11 percent of 9,851 blank)—According to OAR, this field is used when an adverse action is proposed for an employee  There are some actions that are not proposed, such as probationary terminations or admonishments that may be taken without being proposed, and therefore result in this field being blank  Our analysis found that about 95 percent of these records containing blank proposed date fields also had an entry in the proposed adverse-action field, which contained such entries as removals, suspensions, and demotions that require a proposed date  Deciding Official (14 percent of 9,851 blank)—According to OAR, this field should be populated with the name of the official who issued the action taken  Effective Date (5 percent of 9,851 blank)—According to OAR, this field should be populated with the date of the action taken  Some entries will not have an effective date if an entry is pending decision  Also, if no action is taken, the decision was counseling, or the proposed action was rescinded, this field may not have an effective date  Our review found that about 14 percent of the cases that included adverse actions, such as a suspension, removal, reassignment, or demotion, and that should have included a date of action, were blank  Offense 2 and 3 (79 and 95 percent of 9,851 blank)—According to OAR, this field tracks the second- and third-most-significant charge against the employee when applicable  Proposing Official (16 percent of 9,851 blank)—According to OAR, this field should be populated with the name of the official who makes the proposed adverse action  Instances where a proposing official has left the agency at the time of entry and could not be found in the lookup feature that relies on the e-mail global address list may produce blank fields  Also, disciplinary actions that were taken without proposal would not have a proposing official  In these instances, the human-resources specialists who enter the actions are instructed to include the name in the other-comments box  Our review of these records indicated that a majority of records lacking an entry in the proposing official field also lacked an annotation in the other- comments field to accurately identify the proposing official  Settlement (14 percent of 9,851 blank)—According to OAR, this field tracks whether a settlement agreement occurred  This data file is designed to collect allegations of criminal activity, waste, abuse, and mismanagement received by the OIG Hotline Division  Through our analysis of this information system, we identified one field out of seven that was missing information that could be used to analyze misconduct  Nature of Complaint (54 percent of 896 blank)—According to the OIG, this field should contain a brief description of the issue that most closely matches the allegation  Each case can have more than one nature of complaint and corresponding administrative action, if any  OIG officials stated that this field identifies the type of allegations being investigated and should never be blank  Our review of these cases found that over half of the cases involving the OIG contained entries for administrative action taken, but the nature-of-complaint fields corresponding to these actions were blank  This data file is designed to track misconduct and disciplinary action taken against VBA employees  Through our analysis of this spreadsheet, we identified 3 fields out of 20 that were missing information that could be used to analyze misconduct  Alleged Offense 2 and 3 (92 and 99 percent of 1,375 blank)— According to VBA officials, this field should be populated if an individual is charged with multiple offenses, or has additional offenses in the same reporting period  In most instances, there is typically only one offense at the time of reporting  Sustained (52 percent of 1,375 blank)—According to VBA, this field should be populated if an offense is sustained at the time of reporting  This data file is designed to track all allegations of misconduct and associated disciplinary actions taken against VA employees  Through our analysis of this spreadsheet, we identified 8 fields out of 34 that were missing information that could be used to analyze misconduct  Deciding Official (3 percent of 5,571 blank)—According to OAWP, this field should be populated with the name of the official who makes the decision for adverse action  Detail Position (89 percent of 5,571 blank)—According to OAWP, this field should be populated with the position an employee was detailed to if removed from official position  Offense 2 and 3 (69 and 91 percent of 5,571 blank)—According to OAWP, this field tracks the most-significant charges against the employee  If there are fewer than three charges, these fields are left blank  Offense 1 Sustained (14 percent of 5,571 blank)—According to OAWP, this field should be populated if an individual’s first offense has been sustained  Offense 2 and 3 Sustained (73 and 91 percent of 5,571 blank)— According to OAWP, these fields should be populated if an individual’s second and third offenses have been sustained  The majority of cases only involve one offense  Proposing Official (9 percent of 5,571 blank)—According to OAWP, this field should be populated with the name of the official who makes the proposed adverse action  This data file tracks Equal Employment Opportunity (EEO) discrimination complaints  Through our analysis of this information system, we identified 1 field out of 66 that did not have standardization that could be useful to analyze misconduct  Employment—We found that the values for this field were not mutually exclusive, or independent of one another  For example, this field includes two distinct categories of information: employment status, such as full time or part time; and hiring authority, such as Title 5 or Title 38  This method of storing information resulted in undercounting each of the separate values due to the system’s failure to account for expected overlap  For instance, an employee could be both a full-time and Title 5 employee and the field only tracks one or the other  ORM officials stated that this field has since been modified to capture more options to account for the overlap  This data file is designed to track misconduct and disciplinary actions taken against Department of Veterans Affairs (VA) employees  Through our analysis of this spreadsheet, we identified 1 field out of 21 that did not have standardization that could be useful to analyze misconduct  Position—We found the VA-Wide Adverse Employment Action Database contained variations within this field, such as multiple values for the “Cemetery Caretaker” position name  According to OAR, this field is a free-text field, and the office conducts manual searches to review and analyze position titles when needed  Our review found that the different variations in position titles made it difficult to successfully determine the frequency and nature of allegations by position  This is an information system designed to collect allegations of criminal activity, waste, abuse, and mismanagement received by the OIG Hotline Division  Through our analysis of this data file, we identified 1 field out of 7 that did not have standardization that could be useful to analyze misconduct  Nature of Complaint—Our review of the Master Case Index file found variations of similar values in this field  For example, this field contained 21 different claim types pertaining to similar types of fraud, which made it difficult to assess the frequency and nature of claims entered into the system  OIG officials stated that they do not attempt to account for these variations or assess the frequency of use because they are assigned based on a “best match” to the allegations of the case  This data file is designed to track misconduct and disciplinary action taken against VBA employees  Through our analysis of this spreadsheet, we identified 1 field out of 20 that did not have standardization that could be useful to analyze misconduct  Position—Our review found some duplication and overlapping values among this field  For example, the position title for “service representative” contained 21 similar categories with numerous variations in spelling (i e , Veteran Service Representative vs  Veterans Service Representative, and Rating Veteran Service Representative vs  Rating Veterans Service Representative)  We were unable to verify the number of distinct positions due to the lack of standardization within this field  This data file is a tracking spreadsheet for monitoring misconduct and disciplinary action workload  Through our analysis of this spreadsheet, we identified 5 fields out of 12 that did not have standardization that could be useful to analyze misconduct  Action Proposed/Decided/Taken—We were unable to analyze this data field because the action taken was tracked in one single field and updated with the most-recent action, rather than each distinct action being entered in a separate field  Consequently, we were not able to distinguish those cases where corrective action may have been taken, to verify whether the corrective action had been implemented  Current Status—We were unable to analyze this data field because it was not a standardized field  For example, we were unable to determine the total number of cases that were closed, open, or pending due to the variations in the data field (e g , Open, open, open – pending, open-pending)  Full Name of Employee, Grievant, Appellant, Complainant, Non- Employee—We were unable to distinguish whether the individual filing a complaint was an employee, grievant, appellant, complainant, or nonemployee because the information entered into this single field only provided the employee’s full name and did not provide a distinction as to which category the record was assigned, as indicated by the field name  NCA Facility—We were unable to analyze this data field because it was not a standardized field  For example, we were unable to run demographic information on the different facilities involved because this field contained erroneous information  Examples of erroneous information included the name of the Memorial Service Network in one case, and the region, rather than the facility name, in another  Supervisor Name—We were unable to analyze this data field because it was not a standardized field  For example, we were unable to determine the total number of supervisors that were associated with each case due to the variations in the names entered within this field, which included misspelled first or last names, addition/omission of middle initials, or no first name  This data file is a tracking spreadsheet for all allegations received by the VA Secretary regarding misconduct, patient care, or other wrongdoing  Through our analysis of this spreadsheet, we identified 1 field out of 9 that did not have standardization that could be useful to analyze misconduct  Subject—Our review of this tracking spreadsheet found over 380 different possible categories that could be assigned to one record  These categories contained a significant number of variations  For example, we found 38 different categories that contained possible EEO-related issues such as “EEO/Whistleblower,” “Potential EEO,” and “EEO Violations ” We were unable to distinguish the different subject categories for this field due to the lack of standardization  CSRT officials stated that ExecVA reports contain only data corresponding to specific search criteria  This is an information system for tracking allegations of misconduct at all VA facilities that include violation of law and misdemeanors  Through our analysis of this data file, we identified 3 fields out of 29 that did not have standardization that could be useful to analyze misconduct  Classification—We found that this field contained at least three different variations of assault categories (i e , assault, assault-other, and assault-aggravated)  VAPS officials stated that this field is determined and entered by the user  Crime Type—We found this field contained at least five different variations of alcohol-consumption categories, such as “entering premises under the influence” and “alcohol – under the influence ” VAPS officials stated that this field is determined and entered by the user  Final Disposition—We found this field contained at least two different variations of charge type (i e , charged, charged – Issued Ticket), six different variations of open type (for example, open/referred to Court, open/cvb), and two different variations of closed type (i e , closed, case closed)  VAPS officials stated that this field is determined and entered by the user  This data file is designed to track all allegations of misconduct and associated disciplinary actions taken against VA employees  Through our analysis of this spreadsheet, we identified 1 field out of 34 that did not have standardization that could be useful to analyze misconduct  Position Title—We found this field contained at least 15 different variations of Registered Nurse, such as “Registered Nurse,” “Staff RN,” and “RN ” Allegations surrounding inadequate staffing, patient care, and safety at a Department of Veterans Affairs (VA) emergency room were investigated by the medical center director of the facility  The medical center director found that the inadequate patient care and safety issue was unsubstantiated based on a review of patient safety incidents for the last 6 months  The medical center director did not provide a copy of her report review to support this conclusion  She also indicated that an external consultant was hired to assess staffing issues, and found generally that improvements could be made for staffing to address surge capacity  The director stated the medical center was in the process of implementing the recommendations made by the consultant, but her response did not discuss the specific improvements planned or include the external consultant’s report  A fact-finding was performed by a panel comprised of VA Connecticut Healthcare System officials in response to alleged violations of law, gross mismanagement, and waste of funds that included the improper billing of services for a Las Vegas conference and paying contracts through a VA nonprofit corporation to handle such expenditures  The allegations specifically requested a cost-benefit analysis for the conference location  The response received from the program office stated that an outside accounting firm performs an annual financial audit of the VA nonprofit corporation and found no material issues  Neither a copy of the annual financial audit nor a cost-benefit analysis was provided in the response as support  Additionally, the response did not address allegations regarding the status of several essential positions vacated over the prior 3 years  Allegations involved time-and-attendance abuse by a physician who was accused of not responding to calls from peers or coming into the clinic, in favor of his private practice  According to the complainant, physician assistants (PA) examine the physician’s patients at the clinic for him  The medical center director, who was also named in the allegation as having received a similar complaint against the physician 2 years earlier, reviewed the case against the physician and himself  The medical center director’s response claimed that the location indicated in the allegation was not a private practice, but rather a location where the physician reviews medical records and sometimes serves as an expert witness  He did not provide evidence to support his claim  The medical center director also stated that he had not received any reports against the physician for missed calls or clinics and that PAs are expected to participate in these activities  However, he did not provide the physician’s work log, or the PA position descriptions showing that they are allowed to perform these functions autonomously  Finally, the medical center director claimed he did not recall the allegation made against the physician 2 years prior and neither formally substantiated nor disproved the current allegations against the physician  No recommendations were made  The medical center director was accused of hiring an unqualified individual to a Quality Manager position due to their romantic relationship  The response received from the human-resources consultant noted that it was unusual to find a Nurse II manager with only an associate’s degree, but was not illegal, and the employee was qualified based on prior experience  Concerns were also raised concerning the medical center director’s use of over $400 in government funds to “soundproof” the Quality Manager’s office, including having panels attached to one wall and the hollow office door replaced with a solid door  The Chief of Engineering Services was interviewed regarding the request and stated it was an odd request, and the first time he was asked to soundproof an administrative employee’s office  The response provided by the program office did not address why the director used government funds to soundproof the Quality Manager’s office  The response provided also did not address whether recommendations that the Quality Manager’s retention allowance be reviewed for compliance and that she be counseled for appropriate office dress code were implemented  The medical center director was alleged to have misrepresented a plan to track and provide mental-health services to veterans in non-VA hospitals and created a hostile work environment against African-American veterans and employees  The medical center director investigated the allegations against himself and provided a response that was eventually submitted late to the OIG  His response indicated that a review was completed and all allegations were unsubstantiated  Several documents provided with his response showed that only 12 contacts were made to veterans with mental-health care needs during the requested 24-month period, the percentage of patients experiencing wait times greater than 14 days before receiving mental-health services averaged 18 percent, and two veteran suicides occurred  The medical center director did not address allegations of creating a hostile work environment for African American veterans and employees  The medical center director improperly reannounced a vacancy in order to hire an individual with whom he allegedly had a close personal relationship to an Assistant Director position  He also requested the master key to the facility be issued to her against regulations  The allegation involving the master key was substantiated, but the Deputy Under Secretary who conducted the investigation stated that while there was no record of the key being returned, the key was returned and the general engineer brought the facility into compliance with VA regulations  Nonetheless, the Deputy Under Secretary found that a master key was issued in violation of policy, but no recommendations were made to the medical center director for corrective action  Allegations involved false patient wait-time documentation and abuse of authority  Specifically, a medical center director instructed staff to falsify patient wait times between follow-up appointments in order to meet VA’s 14-day timeliness metric  The investigation concluded that the false documentation allegation was substantiated, but attributed the cause to staff not understanding how to enter a follow-up appointment date into the system  It was also concluded that the correction of several hundred dates in the system improved the performance of the department for the national wait-time metric  However, no documentation was provided to (1) prove the medical center director had not abused his authority by instructing staff to review wait times greater than 14 days to determine how they could be reduced, and (2) support the conclusion that the original wait times were entered in error  In addition to the contact above, Dave Bruno (Assistant Director), Erica Varner (Analyst in Charge), Hiwotte Amare, Chris Cronin, Carrie Davidson, Ranya Elias, Colin Fallon, Mitch Karpman, Grant Mallie, Anna Maria Ortiz, Sabrina Streagle, Reed Van Beveren, and April Van Cleef made key contributions to this report 

ground_truth: This report focuses on previous activity in Congress regarding high profile incidents of sexual assault in the military during the summer 2013 through 2016. Included are separate sections on the official responses related to these incidents by the Department of Defense (DOD), the Obama Administration, and Congress including legislation during the 113th (2013-2014) Congress and 114th Congress (2015-2016). The last section is a resource guide for sources in this report and related materials on sexual assault and prevention during this period. This report will not be updated and supersedes CRS Report R43168, Military Sexual Assault: Chronology of Activity in Congress and Related Resources. For current information regarding Congress and issues on sexual assault in the military, see CRS Report R44944, Military Sexual Assault: A Framework for Congressional Oversight, by Kristy N. Kamarck and Barbara Salazar Torreon. For legislative initiatives in the 115th Congress, see CRS Report R44923, FY2018 National Defense Authorization Act: Selected Military Personnel Issues, by Kristy N. Kamarck, Lawrence Kapp, and Barbara Salazar Torreon and CRS Report R45343, FY2019 National Defense Authorization Act: Selected Military Personnel Issues, by Bryce H. P. Mendez et al.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.

Report 1: The last several years have seen renewed debate over the role that race plays in higher education—a debate over "affirmative action " A high-profile lawsuit challenging Harvard University's consideration of race in admitting its incoming classes, and the recent withdrawal of Obama Administration-era guidance addressing similar race-conscious policies, have focused the debate on "affirmative action" in perhaps its more familiar sense: the voluntary consideration of student applicants' race as a way of increasing the participation of racial minorities in higher education  Meanwhile, a recent lawsuit involving Maryland's university system has brought renewed attention to "affirmative action" in its other, original sense: the mandatory use of race by public higher education systems to eliminate the remnants of state-imposed racial segregation  This report addresses "affirmative action" in each of these two senses and discusses how the federal courts have analyzed them under the Fourteenth Amendment's guarantee of "equal protection " The report first considers "affirmative action" in its original sense: the mandatory race-conscious measures that the federal courts have imposed on de jure segregated public university systems  The Supreme Court has made clear that a state that had a segregated system of education must eliminate all "vestiges" of that system, including through expressly race-conscious remedies  In its consequential 1992 decision United States v  Fordice , the Court charted a three-step inquiry for assessing whether a state has fulfilled that constitutional obligation, examining whether a current policy is traceable to the de jure segregated system, has continued discriminatory effect, and can be modified or practicably eliminated consistent with sound educational policy  Outside this de jure context, "affirmative action" has come to refer to a different category of race-conscious policies  These involve what the Court once called the "benign" use of racial classifications —voluntary measures designed not directly to remedy past governmental discrimination, but to increase the representation of racial minorities previously excluded from various societal institutions  And in the context of higher education the Court has addressed one type of policy in particular: the use of race as a factor in admissions decisions, a practice now observed by many public and private colleges and universities  As this report explains, the federal courts have come to subject these voluntary "affirmative action" policies to a particularly searching form of review, known today as strict scrutiny  And they have so far upheld those policies under a single theory: that the educational benefits that flow from a diverse student body uniquely justify some consideration of race when deciding how to assemble an incoming class  To rely on that diversity rationale, however, the Court now requires universities to articulate in concrete and precise terms what their diversity-related goals are, and why they have chosen those goals in particular  And even once those goals are established, a university must still show that its admissions policy achieves its diversity-related goals as precisely as possible, while ultimately "treat[ing] each applicant as an individual " Because both lines of cases discussed here have their roots in the Equal Protection Clause, this report focuses primarily on public universities, all of which are directly subject to constitutional requirements  But those same requirements apply equally to private colleges and universities that receive federal funds pursuant to Title VI of the Civil Rights Act of 1964 (Title VI or the Act), which similarly prohibits recipients of federal dollars from discriminating on the basis of race  This report concludes by discussing the role that Title VI plays in ensuring equal protection in higher education, both public and private, including several avenues for congressional action under the Act  Though government-sanctioned racial segregation in public education is commonly associated with primary and secondary schools, numerous states had also mandated or permitted racial segregation in institutions of higher education, including through the latter part of the 20 th century, categorically excluding black students solely because of their race  Though the Supreme Court held decades ago that state-sanctioned racial segregation in higher education violates the Equal Protection Clause, such intentional segregation, or practices arising from formerly de jure segregated university systems and their discriminatory effects, may still persist  Addressing such circumstances, the Supreme Court has held the Equal Protection Clause to require states to eliminate all vestiges of their formerly de jure segregated public university systems that continue to have discriminatory effect  As the Court concluded in United States v  Fordice , state actors "shall be adjudged in violation of the Constitution and Title VI [of the Civil Rights Act]" to the extent they have failed to satisfy this affirmative duty to dismantle a de jure segregated public university system  A state actor therefore remains in violation of the Equal Protection Clause today if it maintains a policy or practice "traceable" to a formerly de jure segregated public university system that continues to foster racial segregation  Where such a violation is shown, race-conscious measures are not only constitutionally permissible, but may be constitutionally required to remedy and eliminate such unconstitutional remnants  As in the K-12 context, a number of states maintained racially segregated public university systems and denied black students admission to post-secondary schools—including colleges, law schools, and doctoral programs —on the basis that these institutions educated white students only  Prior to 1954—the year of the Supreme Court's landmark Brown v  Board of Education decision ( Brown I ) —the Court had interpreted the Equal Protection Clause to permit state-sanctioned racially segregated public educational systems, provided that the separate schools for black students were substantially equal to those reserved for white students  For example, in its 1950 decision Sweatt v  Painter , the Court addressed an equal protection claim raised by a black student challenging the University of Texas Law School's denial of his admission based on his race, pursuant to its white-only admissions policy  At the time of the plaintiff's application in 1946, the state did not have a law school that admitted black students  Denying the plaintiff's requested relief for admission, the state trial court instead granted additional time to Texas to create a law school for black students; the state thereafter created a law school at the Texas State University for Negroes  The Supreme Court, however, held that the law school—which, among other features, lacked accreditation —did not offer an education "substantially equal" to that which the plaintiff would receive at the University of Texas Law School  On that basis—the absence of a separate but equivalent legal education—the Court held that the Equal Protection Clause required the plaintiff's admission to the University of Texas Law School  A decisive turn in the Court's interpretation and application of the Equal Protection Clause, however, came by way of its 1954 decision in Brown I   There, the Court held for the first time that race-based segregation "in the field of public education" violates the Equal Protection Clause  The Court concluded that race-based segregation in public schools deprives minority students of equal educational opportunities, and observed that segregation commonly denotes inferiority of the minority group  Segregated educational facilities, the Court concluded, are "inherently unequal " The Court's holding in Brown I applies with equal force to public higher education—that is, to public colleges and universities —as does the Court's subsequent 1955 decision in the same case (" Brown II "), in which the Court addressed how school authorities and federal courts were to implement the mandate of Brown I   Indeed, one of the Court's earliest applications of Brown I and Brown II was in the higher education context  In that case, State of Fla  Ex  Rel  Hawkins v  Board of Control , the Supreme Court vacated a Florida supreme court decision that declined to order the state's white-only law school to admit a black student  Relying on language in Brown II that courts could consider practical obstacles to a school's transition to desegregation, the Florida court refused to order the plaintiff's admission  The Supreme Court vacated the state court's decision, concluding that in the case of admitting a black student "to a graduate professional school, there [wa]s no reason for delay" and that he was "entitled to prompt admission under the rules and regulations applicable to other qualified candidates " Following Brown I and Brown II , the Court's equal protection jurisprudence in the public education context expanded significantly to address questions regarding the scope and sufficiency of state actions to "dismantle" racially segregated systems in public school districts across the country, and various challenges to district court-ordered remedies  As the Court revisited these legal standards over time, it continued to describe the affirmative duty of formerly segregated public school entities as the duty to "take all steps necessary to eliminate the vestiges of the unconstitutional de jure system" to the extent practicable  Turning to the context of higher education, the Court addressed, in its 1992 decision United States v  Fordice , how these equal protection principles and legal standards apply to a state's affirmative duty to dismantle a formerly de jure segregated public university system  Though it had "many occasions to evaluate whether a public school district has met its affirmative obligation to dismantle its prior de jure segregated system in elementary and secondary schools," the Court explained, Fordice presented the issue of "what standards to apply" in determining whether the state has met this obligation in the university context  At issue before the Court was Mississippi's prior de jure public university system  The Court observed that since establishing the University of Mississippi as an institution of "higher education exclusively of white persons" in 1848, Mississippi had created four more exclusively white institutions and three exclusively black institutions through 1950  Thereafter, it continued to maintain its racially segregated public university system, and admitted its first black student to the University of Mississippi in 1962 "only by court order " For the "next 12 years," the state's segregated university system "remained largely intact " Around 1987, when the case went to trial, over 99 percent of the state's white students attended the five universities that had been formerly white-only, while the three formerly black-only institutions had student bodies between 92 percent to 99 percent black  Citing its precedent addressing de jure segregation in the K-12 context, the Court stated that "[o]ur decisions establish that a [s]tate does not satisfy its constitutional obligations until it eradicates policies and practices traceable to its prior de jure dual system that continue to foster segregation " Perhaps critically, in the context of remedying a formerly de jure segregated system, a state's "adoption and implementation of race-neutral policies alone " is not sufficient to demonstrate that it has "completely abandoned its prior dual system " Aside from segregative admissions policies, the Court explained, a state's other policies may shape and determine student choice and attendance, and continue to foster segregation  Instead, to determine whether a state has satisfied its affirmative duty to dismantle its de jure public university system, the Court set out a three-step analysis  First , the analysis examines whether the challenged policy or practice maintained by the state is "traceable to its prior [ de jure ] system " By way of example, the Court identified four policies that, in its view, were "readily apparent" vestiges of de jure segregation: admissions standards based on a test-score range originally adopted for discriminatory reasons; unnecessary program duplication throughout the university system (e g , multiple institutions offering the same "nonbasic" courses); the state's academic mission assignments to its higher education institutions (e g , assigning the broadest academic missions to only formerly white-only institutions and the narrowest academic mission to a formerly black-only institution); and the continued operation of all public universities established in the de jure segregated system  With respect to traceability, the Court's analysis reflects that where a current policy functions based on distinctions or a framework created in a formerly de jure system, traceability can be shown  For example, when concluding that the state's designation of academic missions to its universities was traceable to de jure segregation, the Court cited evidence that the state's current method of assigning its universities into three academic missions levels largely mirrored a three-tiered grouping of its universities in the de jure system  In addition and more generally, an interim change or new, nondiscriminatory justification for a current policy does not necessarily sever its traceability to a de jure system  Where the traceability of a policy or policies is shown, a party need not show discriminatory intent with respect to those challenged policies  Where traceability is not shown—that is, where the policies "do not have such historical antecedents" to de jure segregation—an equal protection challenge would then require "a showing of discriminatory purpose " In those instances, the Court explained, "the question becomes whether the fact of racial separation establishes a new violation of the Fourteenth Amendment under traditional principles " Second , once traceability is shown, the analysis turns to whether those traceable policies have continued discriminatory or "segregative" effects in student choice, enrollment, or other facets of the university system  At this stage, the Court noted that a court should not consider "this issue in isolation," but rather examine the "combined effects" of all the challenged policies together "in evaluating whether the State ha[s] met its duty to dismantle its prior de jure segregated system " In light of this instruction, it appears the focus of the second step of the test is not on establishing causation between specific racial disparities and specific policies—by this stage, a court has already found traceability—but rather to evaluate whether a state has sufficiently dismantled its formerly de jure system  Consistent with the state's burden of proving it has dismantled its de jure segregated system, the state must show the absence of segregative effects; plaintiffs are not required to establish this second element  Third , because traceable policies that have discriminatory effects "run afoul of the Equal Protection Clause," such policies must accordingly "be reformed to the extent practicable and consistent with sound educational practices " Thus, at the third step, a court assesses whether traceable policies can be "practicably eliminated" "consistent with sound educational practices," with the burden on the state to show that the challenged policies are "not susceptible to elimination without eroding sound educational policy " Because the Court remanded the case to the lower court to address practicable elimination, its analysis in Fordice on this point is limited  The Court suggested, however, that if a current policy lacks sound educational justification, it reasonably follows that it can be practicably eliminated in part or in whole  In addition, the Court observed that in some cases, a merger or closure of institutions could be constitutionally required to eliminate vestiges, should other methods fail to eliminate their discriminatory effects  Finally, the Court repeatedly stated that so long as vestiges remain, which have discriminatory effects, the state remains in violation of the Equal Protection Clause unless it can show it cannot practicably eliminate those policies or practices  In addition, Justice O'Connor, in a separate concurring opinion in Fordice , emphasized the "narrow" circumstances under which a state could maintain a traceable policy or practice with segregative effects  In her view, courts may "infer lack of good faith" on the part of the state if it could accomplish educational objectives through less segregative means, and the state has a "'heavy burden'" to explain its preference for retaining the challenged practice  Moreover, even if the state shows that retaining certain traceable policies or practices is "essential to accomplish its legitimate goals," Justice O'Connor asserted that the state must still prove it has "counteracted and minimized the segregative impact of such policies to the extent possible " The Court in Fordice observed that the closure or merger of certain institutions may be constitutionally required, consistent with its holding that any vestige of a de jure segregated system that continues to have discriminatory effect must be eliminated to the extent practicable and consistent with sound educational policy  Yet that invited a new—and more difficult—set of questions: which institutions would be most subject to closure or merger, and under what circumstances would such action be required? Significantly, the Court did not categorically identify which institutions would be most subject to such remedial action —a state's flagship, formerly white-only institutions from which a de jure system originated, for example, or formerly black-only institutions created to preserve white-only admission at other institutions  Instead, the Court concluded that it was unable to determine—on the record presented in Fordice —whether closures or mergers were required in that case and directed the lower court on remand to "carefully explore" several considerations  This instruction to the lower court, while not part of the holding in Fordice , suggests that several factors are relevant for determining whether merger or closure is constitutionally required  In addition, the Court observed that maintaining all eight higher education institutions in Mississippi was "wasteful and irrational," particularly in light of the close geographic proximity between some of the universities  This observation suggests that close proximity between institutions offering similar programs could be a relevant factor in assessing remedial closure or merger as well  Regarding the fate of a state's historically black institutions, Justice Thomas, in a concurring opinion, did not read Fordice to "forbid[]" those institutions' continued operation or "foreclose the possibility that there exists 'sound educational justification' for maintaining historically black colleges as such  " Justice Thomas emphasized that "[d]espite the shameful history of state-enforced segregation," historically black colleges and universities were and remain institutions critical to the academic flourishing and leadership development of many students, and observed that "[i]t would be ironic, to say the least, if the institutions that sustained blacks during segregation were themselves destroyed in an effort to combat its vestiges " In his view, though a state is not constitutionally required to maintain its historically black institutions as such, their continued operation is constitutionally permissible, so long as admission is open to all students "on a race-neutral basis, but with established traditions and programs that might disproportionately appeal to one race or another " Following Fordice , plaintiffs, including the United States in Title VI enforcement actions, have brought suit challenging practices allegedly traceable to a state's de jure segregated university system  Challenged practices have included unnecessary program duplication, which the Court identified in Fordice as one of the "readily apparent" remnants of de jure segregation, as well as others such as scholarship policies, funding practices, and the use of curricula at formerly white-only institutions with little representation of black history and culture  More recently, in 2018, a legal challenge against the State of Maryland alleged that practices relating to capital and operational funding, unnecessary program duplication, and the limited institutional missions of the state's formerly black-only institutions are traceable to the state's formerly de jure segregated higher education system  To date, however, only a few federal appellate courts have had occasion to analyze Fordice -based claims, and the Supreme Court has not, since its 1992 decision, addressed claims challenging higher education policies or practices as unconstitutional vestiges of de jure segregation  Though development of the Fordice standard in federal case law is limited, the few appellate decisions applying Fordice provide at least some analytical examples and reflect discernible differences in approach, particularly with respect to the evidence sufficient to satisfy the third element of the Fordice standard—that elimination of a practice is not possible, despite being traceable and having continued discriminatory effect  As discussed above, the Supreme Court in Fordice identified "unnecessary program duplication" as a practice traceable to the prior de jure segregated system of higher education at issue in that case, stating that "it can hardly be denied" that such duplication was a requisite feature of the prior dual system because "the whole notion of 'separate but equal' required duplicative programs in two sets of schools " Drawing upon that rationale, courts that have addressed unnecessary program duplication have generally had little difficulty tracing duplicative courses and degree programs to prior de jure segregation  On the matter of if and how program duplication might be eliminated, however, there is lesser consensus  Generally, federal courts have considered several methods for eliminating program duplication, such as transferring existing programs from one institution to another, eliminating certain programs altogether, creating cooperative programs, and—perhaps most drastically—merging institutions  Plaintiffs have also raised equal protection challenges to state funding practices that allocate all or most of their federal and state land grants to institutions that were formerly white-only in a de jure system while dedicating significantly less or no funds to formerly black-only institutions  More specifically, these cases have concerned a state's allocation of federal land grants provided annually to support research on agricultural issues and the dissemination or "extension" of that research  At issue in Knight v  Alabama , for example, was the State of Alabama's allocation of federal funds between its two land grant universities, Auburn University, formerly white-only in the de jure system, and Alabama A&M University (A&M), formerly established as black-only  The state allocated to Auburn the entirety of Alabama's approximately $4 million in federal aid for agricultural research, and allocated an additional $14 million to Auburn in state funds  Meanwhile, the state had "for years" allocated no federal aid to A&M and given state funds for agricultural research in amounts that "today still totals less than $200,000 each year " The U S  Court of Appeals for the Eleventh Circuit held that the state's current funding allocation was traceable to de jure segregation and instructed the lower court on remand to make determinations with respect to the second and third parts of the Fordice test  On the issue of practicable elimination, the Eleventh Circuit observed that reduced efficiency would not necessarily render a proposed modification impracticable or educationally unsound  By contrast, the Fifth Circuit affirmed a district court's ruling that permitted a state to retain its traceable funding practices  There, despite finding traceability and discriminatory effects, the district court had concluded, based on inefficiencies related to running more than one agricultural research program, that it was not practicable for the state to eliminate its exclusive funding allocation to its formerly white-only land grant institution  The Supreme Court has not revisited its analysis in Fordice , leaving open questions about the permissible applications of its three-part legal standard to an array of fact patterns and legal theories  Similarly, as discussed above, few courts of appeals have addressed claims under Fordice , limiting the development and interpretation of Fordice in federal case law  One such unresolved question is under what circumstances, if any, traceability can be established under Fordice when a state makes changes to an originally discriminatory policy such that the current policy functions differently, but there is still some evidence of traceability between the two, or perpetuation of similar segregative effects under the changed policy as under the original policy  In addition, the Supreme Court and circuit courts have not yet expressly addressed how far a district court may go in remedying an unconstitutional vestige or remnant of a prior de jure public university system  In the K-12 context, the Supreme Court has upheld district court orders that set certain faculty and student ratios at schools in noncompliant school districts, to desegregate them pursuant to Brown and its progeny   It remains unclear, however, whether the district courts enjoy similar authority under Fordice to order similarly extensive remedies  Indeed, the few cases alleging Fordice -type claims that did reach the federal appellate courts ultimately resolved in settlements, thus leaving little judicial guidance on the scope of a court's authority to mandate specific remedies if a state fails to dismantle its formerly de jure segregated public university system  With respect to these unresolved questions, the Supreme Court's express reliance in Fordice on precedent addressing de jure segregation in the primary and secondary school context suggests that at least some of this same precedent should inform future analyses, with adaptation to the higher education context  A finding of a state entity's intent to segregate students by race in the higher education context is critical to showing a violation of the Equal Protection Clause, and has significant legal consequences  In such cases of de jure —that is, intentional, state-imposed —segregation, the state has an affirmative duty under the Equal Protection Clause to eliminate all vestiges of its de jure system by dismantling the infrastructure and other mechanisms that produced the discriminatory segregation  According to the Supreme Court's 1992 Fordice decision, this duty commands more than just the repeal of state laws sanctioning racial segregation in higher education  The state must also uproot or reform any policy or practice "traceable" to its formerly de jure system that continues to have discriminatory effect  In Fordice , the state's intent to racially segregate its higher education system was plain: with the founding of the University of Mississippi in 1848, Mississippi explicitly set out to create a public university "dedicated to the higher education exclusively of white persons," and racially segregated its public university system over the next 100 years through the creation of other "exclusively white institutions" and "solely black institutions " Nor was Mississippi's system unique in this regard  "[D]ual system[s]" of public higher education—one for black students, another for white—were codified in other state and local laws throughout the country  Thus far, federal courts that have addressed de jure segregation in higher education have done so in the context of such codified segregation, as in Fordice   The absence of a codified dual system of higher education, however, may not mean that a university system was not or is not intentionally segregated  As reflected in the Supreme Court decision Keyes v  School District No  1, Denver, Colorado , even when state authorities have not segregated their public schools by statute, they may still have engaged in unconstitutional racial segregation  Thus, in the K-12 context, federal courts have found de jure segregation based on evidence reflecting a state actor's impermissible segregative intent  This line of cases would appear to apply in the context of higher education as well  As the Court noted in Fordice , where a plaintiff is unable to show that a policy or practice is a vestige of prior de jure segregation, she may nonetheless prove a "new" constitutional violation with evidence of a present-day intent to racially segregate students "under traditional principles" governing discriminatory intent  This would be consistent with the Court's application of Brown and its progeny broadly across "the field of public education," including higher education, as reflected in Fordice   Because the Supreme Court has yet to address segregative intent in higher education, it is unclear what intent evidence would be sufficient to establish a de jure segregated public university or institution, apart from a law codifying such segregation  As a general matter, though, a court's determination of discriminatory intent is a fact-intensive, "sensitive inquiry " And the Supreme Court has observed that this is even more so in cases alleging de jure segregation in public education  Where the evidence indicates, for example, that a state actor undertook a policy or practice knowing that doing so would have the "foreseeable" effect of segregating students by race, that evidence may support an inference of de jure segregation  In addition, at least in the K-12 context, a finding of a state entity's segregative intent in one part of a school system creates a rebuttable presumption that segregation found in other parts of the same system was also intentional  De jure segregation proved by such nonstatutory evidence generally triggers the same affirmative obligation on the state to eliminate the vestiges of its state-imposed segregation, as when de jure segregation is shown through state or local laws  Though segregative intent analyses at the K-12 level may be instructive, the guidance these decisions provide may be limited by the nature of the evidence at issue in those particular cases: the method of student assignment to elementary or secondary schools, for example, or the drawing of attendance zones to create racially segregated schools  It appears unlikely that such evidence would be at issue or directly applicable in cases alleging segregative intent at the collegiate or graduate level  Nonetheless, these decisions generally suggest that categorical distinctions—between evidence indicative of de jure segregation and evidence of existing segregation insufficiently linked to state intent—are difficult to draw  Indeed, given the difficulties that can arise in a court's analysis of "segregative intent," over the years a number of Justices have called into question the rationale and basis for the distinction between de jure and so-called de facto segregation, though the majority of the Court has recognized and continues to recognize this distinction  Whatever the open questions may be regarding the evidence sufficient to show segregative intent, particularly in the higher education context, Fordice instructs that a plaintiff need not provide evidence of new discriminatory intent when alleging that a state has failed to eliminate vestiges of a prior de jure segregated system  And with respect to remedying intentional racial segregation, the Court has repeatedly held that a state not only may use a broad array of explicit race-conscious policies and practices to remedy its constitutional violation, but often must do so  By themselves, race-neutral measures simply may not be enough, the Court has explained, to provide equitable, make-whole relief for intentionally segregative acts  This affirmative obligation to consider race arises, however, only in the context of de jure segregation  Outside that de jure context, institutions of higher education subject to the Equal Protection Clause have no such duty to remedy racial segregation  Nor may they—or the federal courts, for that matter—use the same broad array of race-conscious measures available for remedying de jure segregation  De jure segregation, however, is not the only context in which race-conscious measures in higher education may be used  For over forty years colleges and universities have considered race as a way of increasing the racial diversity of their student bodies, independent from a legal basis relating to de jure segregation  Thus far, however, the Supreme Court has addressed only one type of discretionary race-conscious measure in the higher education context: admissions policies  And when evaluating these discretionary policies, the Court reviews them under a notably different analytical lens, looking to their precision in achieving certain concretely defined and "compelling" educational interests, as explained more fully below  "Affirmative action" in its original sense grew out of the states' affirmative obligation under the Equal Protection Clause to rid their public institutions of the lingering vestiges of de jure segregation  But "affirmative action" has also come to refer to race-conscious policies developed outside this de jure context  These are policies voluntarily adopted by institutions to help racial minorities overcome the effects of their earlier exclusion  And unlike the measures ordered by the courts to right the wrongs of de jure segregation, these policies are strictly voluntary, with their legality consequently turning on constitutional considerations unlike those involved in the de jure context  "Affirmative action" in this more familiar, voluntary sense has also been among the most contentious subjects in constitutional law  In the forty years since Regents of the University of California v  Bakke , when the Court first addressed those programs' constitutionality, the Justices have divided sharply over when or whether such programs can survive constitutional scrutiny  And a major point of disagreement among the Justices—lingering to this day —is how strictly to review those policies and what the government or other state entity must do to justify its use of "benign" racial classifications  In recent decisions, the Court has reviewed such classifications under a seemingly "elastic" regime of strict scrutiny, accepting those classifications only where they have been narrowly tailored to serve compelling government interests  The constitutional guarantee of equal protection broadly prohibits the government from employing "arbitrary classification[s] " And the use of racial classifications in particular has long been of special concern for the courts  Indeed, this "heightened judicial solicitude" for racial categorizing has roots nearly as old as the Fourteenth Amendment itself  As the Supreme Court explained in an early decision under the Amendment, the "spirit and meaning" of the Equal Protection Clause was "that the law in the States shall be the same for the black as for the white; that all persons, whether colored or white, shall stand equal before the laws of the States, and, in regard to the colored race,     that no discrimination shall be made against them by law because of their color " In the decades since, the Court has only made clearer that it regards the government's use of racial classifications as "inherently suspect" and therefore subject to more demanding scrutiny than other classifications, which are typically reviewed only for basic rationality  There has been significant disagreement, however, over just how rigidly the courts should scrutinize a racial classification, especially when the point of the classification is to benefit racial minorities, as in the case of affirmative action  That issue came before the Court for the first time in Bakke , involving a challenge to an affirmative action admissions program begun at the then newly created medical school at the University of California at Davis (the Medical School)  And the Court's fractured decision there prefigured the central disagreements that the Justices still face in reviewing so-called "benign" racial classifications  In the early 1970s, not long after the Medical School opened, it adopted a race-conscious admissions policy to increase its enrollment of certain "disadvantaged" students  Under that policy, the school each year would set aside 16 seats in its entering class of 100 specifically for members of this "disadvantaged" group, to be admitted by a "special admissions" committee  Although many white students sought admission under this "special" policy, the committee considered only students of specifically identified racial minorities  After Allan Bakke, a white male, twice sought—and was denied—admission to the school, he brought suit challenging the set-aside under the Equal Protection Clause as well as Title VI, which prohibits institutional recipients of federal funds—like the Medical School—from discriminating on the basis of race  Bakke's case eventually found its way to the Supreme Court and into the hands of a divided bench  The Justices found themselves particularly at odds over the case's threshold question—what level of scrutiny the Court should apply in reviewing Bakke's challenge  Justice Stevens, writing for a quartet of Justices, concluded that the program violated Title VI, sidestepping the constitutional question  Another four Justices would have reached the equal protection challenge, and in doing so would have required the Medical School to point to "important governmental objectives" that justified its admissions policy's use of "remedial" racial classifications, along with evidence that their use was "substantially related to" achieving those important objectives   Under that standard—a form of intermediate scrutiny —these Justices would have upheld the policy  Justice Powell, announcing the Court's judgment but writing for himself, insisted that all "racial and ethnic distinctions" drawn by the government must be regarded as "inherently suspect," calling for "the most exacting judicial examination " What that meant in Bakke , according to Justice Powell, was that the Medical School would need to prove that its use of the "special admissions" carve-out was "precisely tailored to serve a compelling governmental interest"—the standard of review now known simply as strict scrutiny   And because, in his view, the school could come forward with no such proof, Justice Powell concluded that its affirmative-action policy could not survive the Court's scrutiny, whether under the Fourteenth Amendment or the overlapping standards of Title VI  Because Bakke yielded no majority opinion, it could only hint at how the Court might treat other "benign" race-conscious policies that did not involve the sort of apparent quota invalidated in that case or cases outside the unique context of higher education  That uncertainty would last another decade, as the Court, in another series of splintered decisions, weighed constitutional challenges to differently structured affirmative action policies in other contexts, each time without resolving the appropriate standard of review  That uncertainty appeared to abate with the Court's 1989 decision in Richmond v  J A  Croson , Co  There, for the first time, five Justices clearly signaled that they would apply strict scrutiny to affirmative action plans implemented at the state and local levels, including the program they invalidated in that case, involving the City of Richmond's set-aside of public work funds for minority-owned businesses  But the next year, in Metro Broadcasting, Inc  v  FCC , the Court, in another 5-4 ruling, suggested that it would review federal affirmative action plans differently  In the Court's view there, "benign race-conscious measures mandated by Congress " need only "serve important governmental objectives" and be "substantially related to the achievement of those objectives"—satisfying an intermediate level of scrutiny  Just a few years later, however, in Adarand Constructors, Inc  v  Peńa , the Supreme Court reversed course  There, in a federal contracting case, the Court drew a different lesson from its pre- Metro line of race-classification cases: in the view of the Adarand majority, "any person, of whatever race, has the right to demand that any governmental actor subject to the Constitution justify any racial classification subjecting that person to unequal treatment under the strictest judicial scrutiny " That simple rule therefore precluded the divided regime upheld in Metro Broadcasting , subjecting the states' use of racial classifications to strict scrutiny, while relaxing the review of comparable classifications enacted by Congress  Instead, the Adarand Court held, "[f]ederal racial classifications, like those of a State, must serve a compelling governmental interest, and must be narrowly tailored to further that interest " And to the extent that Metro Broadcasting was "inconsistent" with that uniform rule, it was accordingly overruled  After Adarand strict scrutiny therefore became the test of any classification that subjected individuals to unequal treatment based on their race, no matter which state actor was doing the classifying  And the Court expressly extended that holding to the context of higher education  As the Court reaffirmed in Fisher v  University of Texas , "because racial characteristics so seldom provide a relevant basis for disparate treatment," "[r]ace may not be considered [by a university] unless [its] admissions process can withstand strict scrutiny " It therefore appears that a classification that subjects individuals to unequal treatment because of their race, even if for a "benign" purpose, will have to satisfy strict scrutiny  In its canonical formulation, that test calls for measuring such classifications along the two dimensions Justice Powell identified in Bakke : (1) the classification must serve a compelling governmental interest and (2) the use of that classification must also be narrowly tailored to achieving that interest  The government has the burden of proving both, and neither is easy to do  Indeed, in the sixty years that separated the Court's now-repudiated decision in Korematsu v  United States from Grutter v  Bollinger , when the Court first upheld an affirmative action policy at a public university, the only other "racial classifications upheld under strict scrutiny [have been] race-based remedies for prior racial discrimination by the government " To many commentators "strict scrutiny" has thus come to seem rather more "strict in theory, but fatal in fact" —a point sometimes echoed by the Justices themselves  Strict scrutiny may typically be fatal in fact, but affirmative action policies in higher education have been a notable exception  Partly this has to do with the Equal Protection Clause itself, and the often crucial difference that a particular context makes in deciding cases under that "broad provision[] " And for several Justices the context of affirmative action, involving the arguably "benign" use of race, has seemed particularly distinctive  Yet, despite this contextual difference, the Court has made it clear that its scrutiny of race-conscious admission policies is still every bit as strict  Or, as Justice Kennedy put the point in the first Fisher case, even though "[s]trict scrutiny must not be 'strict in theory, but fatal in fact,'" it must also "not be strict in theory but feeble in fact " This seeming tension—between the strictness of the Court's scrutiny and its approval of race-conscious admissions policies—has led the Court to adjust its framework for scrutinizing similar policies over the years


Report 2:  And since Bakke that framework appears to have shifted in two significant respects, corresponding to each of the two prongs of strict scrutiny  First, the Court now requires public universities that adopt affirmative action admissions policies to explain in increasingly "concrete and precise" terms what diversity-related educational goals those policies serve and why the university has chosen to pursue them  Anything less, the Court has held, would fail to present an interest sufficiently compelling under strict scrutiny  Second, the Court also now expects universities to prove that their policies achieve those "concrete and precise goals" in an appropriately "flexible" way, as most clearly exemplified by the Harvard plan that Justice Powell singled out in Bakke   That model has yielded "five hallmarks" of an appropriately tailored affirmative action policy, criteria that have since guided lower courts in assessing other affirmative action plans  For a university's affirmative action policy to survive strict scrutiny, a university must first "demonstrate with clarity that its 'purpose or interest is both constitutionally permissible and substantial " The Court has recognized only a single interest that meets that standard: "the attainment of a diverse student body " What exactly that interest amounts to—and how, consequently, a university should ensure it has appropriately tailored its policy to achieve that interest—has been a point of uncertainty since Bakke   With its two decisions in Fisher v  University of Texas , however, the Court appears now to require a more "concrete and precise" articulation of the diversity-related educational goals a university hopes to achieve through its affirmative action admissions policy  In addition, the Court also now appears to expect a university to provide a reasoned and principled explanation of why the school believes it important to achieve those goals  The diversity rationale emerged with the Court's first encounter with a voluntary affirmative-action policy, in Bakke   There—in an opinion for the Court joined by no other Justice—Justice Powell explained what interests clearly would not count as compelling enough to satisfy strict scrutiny  Those included the Medical School's alleged interest in having "some specified percentage" of certain racial or ethnic groups in a student body and its interest in "remedying     the effects of societal discrimination," as well as the school's particular interest in "the delivery of health-care services to communities currently underserved " None of these interests, Justice Powell concluded, provided a reason substantial enough to justify turning to race-conscious measures  Nor has the Court said otherwise since  But Justice Powell was also clear about what interest he believed would satisfy strict scrutiny: "student body diversity " And just as importantly, he also explained why: colleges and universities, he suggested, had a uniquely academic interest in promoting an "atmosphere of speculation, experiment, and creation"—an interest, more simply, in "academic freedom " That interest, Justice Powell observed, was not only "essential to the quality of higher education," but had also long "been viewed as a special concern of the First Amendment " Thus the "right to select those students who will contribute the most to the robust exchange of ideas" not only allowed a university "to achieve a goal that is of paramount importance in the fulfillment of its mission," it also represented a "countervailing constitutional interest" that, in Justice Powell's view, called for the Court's respect  In Bakke , Justice Powell set out the basic theory for why diversity could justify an affirmative action policy, at least "in the context of a university's admissions program  But he gave few details about what that interest encompassed  As he saw it, that interest must have its limits: pursuing diversity would not allow a university to resort to racial quotas, for example, nor could the school disregard other "constitutional limitations protecting individual rights " But Justice Powell declined to indicate where those other limitations fell or how they circumscribed the goals a university could permissibly seek in the name of a diverse student body  And because the Bakke Court fractured as it did, with no one opinion commanding a majority of the Justices' votes, the lessons of that case have been hard to discern, especially after the Court appeared to decline a similar diversity rationale in later cases outside higher education  Perhaps unsurprisingly, the lower courts soon came to reflect this uncertain division of opinion in later cases involving affirmative action programs at other public universities  Some clarity over Bakke 's diversity theory came in 2003, with a pair of decisions reviewing affirmative action policies of the University of Michigan: Grutter v  Bollinger , challenging the university's law school admission program, and Gratz v  Bollinger , challenging the policy used by the university's undergraduate program  Grutter , especially, helped clarify what an interest in diversity involved, and how a university could rely on that interest to defend a race-conscious admissions policy  Under the admissions policy of the University of Michigan Law School ( the Law School) challenged in Grutter , applicants to incoming classes were admitted under a policy that weighed a composite of the applicant's LSAT score and undergraduate GPA along with several more individualized factors, including the applicant's race  The Law School set out to create classes with what it called a "critical mass of underrepresented minority students," to ensure that those students felt "encourage[d]     to participate in the classroom and not feel isolated " The school, however, never explicitly assigned a numerical target for any particular racial group, though it did track, on an ongoing basis, "the racial composition of the developing class " A rejected white applicant claimed the Law School's admission policy discriminated against her based on her race, in violation of the Equal Protection Clause and Title VI  And her challenge eventually reached the Supreme Court, alongside its companion case, Gratz , challenging the university's admissions policy for its undergraduate program  Given the uncertainties surrounding Bakke 's bottom line, the first major question in Grutter centered on the basic goal of the Law School's policy: Is achieving student diversity an interest compelling enough to justify a school's use of race at all in its admissions decisions? And for the first time the Supreme Court held that it was  Writing for a clear majority, Justice O'Connor adopted the view Justice Powell set out in Bakke : "student body diversity is a compelling state interest that can justify the use of race in university admissions " More than that, the Court made clear that it was willing to defer to the Law School's understanding of that interest, and its goal of "enroll[ing] a 'critical mass' of minority students '" As Justice O'Connor explained for the Court, by enrolling a "critical mass" of students, the Law School was trying to achieve the "substantial" "educational benefits that diversity is designed to produce"—benefits such as "promot[ing] cross-racial understanding," "break[ing] down racial stereotypes," "promot[ing] learning outcomes," and "better prepar[ing students] as professionals " Achieving a "critical mass" of underrepresented students, the Court agreed, was simply one way that the Law School could try to vindicate those diversity-related educational benefits  And because this interest was deemed compelling enough to satisfy strict scrutiny, the Court was therefore willing to treat the school's use of the "critical mass" target as a permissible proxy for achieving those benefits  Not all the Justices agreed, however, that the university's invocation of "critical mass" made the diversity interest more concrete or compelling  In dissent, Justice Kennedy sided with Chief Justice Rehnquist's view that "the concept of critical mass [was] a delusion used by the Law School to mask its attempt to make race an automatic factor in most instances and to achieve numerical goals indistinguishable from quotas " That "delusion," according to Justice Kennedy, did not just make the school's appeal to "critical mass" "inconsistent with [the] individual consideration" of applicants  It also, in his view, turned the school's admissions policy into a veiled form of racial balancing  And all four dissenting Justices found that result incompatible with the Equal Protection Clause  Grutter appeared to settle the major question left open by the fractured decision in Bakke : whether achieving student diversity was a compelling enough interest for a public university to justify its consideration of race in its admissions policies  Grutter confirmed not only that the Court still viewed student diversity as a compelling interest, but also that a school could vindicate that interest by seeking to enroll a "critical mass" of underrepresented minorities in its incoming classes  The ruling also effectively swept aside contrary lower court decisions that struck down other state universities' affirmative action policies, including in Texas  In the wake of Grutter , the University of Texas (UT Austin) decided to revisit its applicant review process, eventually choosing to introduce race as one of the factors considered in its admissions policy  Under the revised policy, UT Austin would continue to admit all Texas high school students who graduated in the top ten percent of their class, and fill in the rest of its incoming undergraduate classes using an index score incorporating two assessments: (1) an "Academic Index" (AI) that weighed the applicant's SAT score and academic record; and (2) a "Personal Achievement Index" (PAI) that included a more holistic appraisal of the student's character and, following post- Grutter revisions, also factored in the applicant's race  Abigail Fisher, a white Texas student whose application to UT Austin was rejected under this process, challenged the AI-PAI system  That system, she argued, had discriminated against her as a white applicant by allegedly allowing race to figure in the decision to reject her application, in violation of the Equal Protection Clause  Her challenge eventually made its way to the Supreme Court as Fisher v  University of Texas , where the Supreme Court remanded the challenge to the lower court to review UT Austin's policy under strict scrutiny ( Fis her I ), and then upon appeal upheld the school's admission policy ( Fis her II )  In her suit, Fisher did not challenge Grutter 's basic holding—that the university had a compelling interest in student diversity, or even that the school could pursue that interest in diversity by enrolling a "critical mass" of underrepresented minorities  But when the Court finally took up her challenge on the merits in Fisher II , Justice Kennedy also took the occasion to revisit Grutter 's analysis, offering several "controlling principles" on behalf of the four-Justice majority that would guide its review of UT Austin's race-conscious admissions policy  In Fisher II , as in Fisher I , Justice Kennedy confirmed that Grutter 's bottom line remained good law: "obtaining 'the educational benefits that flow from student body diversity,'" he confirmed, was still an interest compelling enough to satisfy strict scrutiny  But perhaps mindful of his dissent in Grutter , Justice Kennedy also clarified that "asserting an interest in the educational benefits of diversity writ large" would not suffice  That, he explained, would make the "university's goals" too "elusory or amorphous" "to permit judicial scrutiny of the policies adopted to reach them " The Court thus cut two new benchmarks for reviewing a university's asserted interest in resorting to race as a factor in its admissions policy  First, the university had to articulate "precise and concrete goals" that its race-conscious policy served, goals "sufficiently measurable" under "judicial scrutiny " And, second, the university had to provide a "'reasoned, principled explanation' for its decision to pursue those goals"—a sound academic rationale, in other words, for wanting to achieve whatever diversity-related goals it set for itself  In the majority's view, UT Austin's use of race in its admissions decisions measured up to both benchmarks  According to the Court, the first benchmark was straightforwardly met: the goals UT Austin articulated, Justice Kennedy pointed out, effectively "mirror[ed] the 'compelling interest' th[e] Court ha[d] approved in its prior cases " And under Grutter , the majority concluded, those benefits passed constitutional muster  Notably, however, achieving critical mass was not among those Justice Kennedy listed  Nor did Justice Kennedy return to the question he raised in Grutter : whether the "critical mass" concept even has a place among the "concrete and precise goals" that could survive strict scrutiny  But that question was also arguably beside the point in Fisher II   As Justice Kennedy emphasized for the Court, the goals that UT Austin articulated were clearly constitutionally adequate, having come nearly verbatim from the Court's case law  And the university's officials had all offered "the same, consistent 'reasoned, principled explanation'" for pursuing them—meeting the Court's second benchmark  That was apparently enough for the Court to conclude that a compelling interest justified the university's diluted use of race in its holistic review of applications  With Fisher I and II , the Court reiterated that the educational benefits that come with a racially diverse student body count among the few interests compelling enough to survive strict scrutiny  But Fisher I and II also narrowed that interest: seeking student body diversity had to involve objectives more specific than the simple desire for "diversity writ large " Rather, under the Fisher formulation, the university must articulate the "concrete and precise goals" it expects its affirmative action policy to accomplish, along with a "reasoned, principled explanation" of why it has chosen to pursue them  So long as a university does that, it will likely have a strong case, under Fisher I and II , that a compelling interest supports its use of a race-conscious admissions policy  That, however, is only the first of two tests that a policy has to pass under strict scrutiny  The second—probing whether the university has narrowly tailored its policy to achieve those diversity-related benefits—has proved equally critical in the Court's review of affirmative action policies  And once again owing to Justice Powell's opinion in Bakke , the Court appears to have embraced a model of what a narrowly tailored policy looks like: Harvard College's admissions program endorsed in Bakke , now more commonly known as the "Harvard plan " The Harvard plan has also provided the Court with a basis for developing more specific criteria for evaluating other affirmative action policies—what one court has described as the "five hallmarks of a narrowly tailored affirmative action plan " The first affirmative action program to come before the Court—the policy challenged in Bakke at U C  Davis's Medical School—was also the first to falter under the Court's scrutiny  But because the Justices were unable to cobble together a majority there, they also settled on no single rationale for why the Medical School's policy could not survive the Court's scrutiny  This uncertainty left the lower courts without clear guidance on the permissibility of race-conscious admissions policies structured differently than the one struck down in Bakke   In announcing the judgment in Bakke , however, Justice Powell offered a clear reason why, in his view, the Medical School's policy could not survive a challenge under the Equal Protection Clause  The school's 16-seat set-aside for minority students was not "the only effective means of serving [the school's] interest in diversity" —in constitutional parlance, the set-aside was not narrowly tailored  And to explain why not, Justice Powell pointed to the Harvard plan as an example of an appropriately tailored affirmative action policy  That plan, according to Justice Powell, had several significant features that distinguished it—favorably—from the set-aside struck down in Bakk e : In [Harvard's] admissions program, race or ethnic background [is] deemed a "plus" in a particular applicant's file, yet it does not insulate the individual from comparison with all other candidates for the available seats  The file of a particular black applicant may be examined for his potential contribution to diversity without the factor of race being decisive when compared, for example, with that of an applicant identified as an Italian-American if the latter is thought to exhibit qualities more likely to promote beneficial educational pluralism  Such qualities could include exceptional personal talents, unique work or service experience, leadership potential, maturity, demonstrated compassion, a history of overcoming disadvantage, ability to communicate with the poor, or other qualifications deemed important     [And] the weight attributed to a particular quality may vary from year to year depending upon the 'mix' both of the student body and the applicants for the incoming class  Unlike this "flexible" system of review, the Medical School policy at issue in Bakke was rigid: reserving a predetermined number of seats for a "selected ethnic group " In Justice Powell's view, that technique effectively precluded a more holistic review, that "treats each applicant as an individual " "[R]ace or ethnic origin," as he saw it, did not serve as "a single though important element" of an applicant's file in the Medical School's policy; it had instead become a factor that "foreclosed" other applicants "from all consideration for [certain] seat[s] simply because [they were] not the right color or had the wrong surname " A program like that, Justice Powell concluded, could not be narrowly tailored—precisely because another more individualized and "holistic" model, like Harvard's, could serve instead  Even if Bakke suggested that the Court's scrutiny of a race-conscious admissions policy would be every bit as strict as for other racial classifications, later cases have made clear that such scrutiny need not always be fatal  The companion cases of Grutter v  Bollinger and Gratz v  Bollinger offer clear examples: each involved affirmative action admissions policies at the University of Michigan, and each yielded a different bottom line, with the Court upholding the Law School's policy in Grutter while striking down the university's undergraduate admissions policy in Gratz   But those diverging results appeared to proceed from a common starting point: how closely the challenged admissions policy resembled the Harvard plan  In the case of the Law School's admissions policy, the Court found the resemblance quite close  As Justice O'Connor explained for the Court in Grutter , "the Law School engages in a highly individualized, holistic review of each applicant's file, giving serious consideration to all the ways an applicant might contribute to a diverse educational environment " It therefore did not award "mechanical, predetermined diversity 'bonuses' based on race or ethnicity " And "[l]ike the Harvard Plan, the Law School's admissions policy" accorded each applicant the same sort of flexible consideration that Justice Powell had called for in Bakke   That "policy st[ood] in sharp contrast," however, with the way the Court viewed the university's undergraduate admissions policy in Gratz   Under the undergraduate policy, admissions officers automatically awarded "20 points, or one-fifth of the points needed to guarantee admission, to every single 'underrepresented minority' applicant solely because of race " As Chief Justice Rehnquist explained for the Court, that policy therefore violated a basic feature of "[t]he admission program Justice Powell described" in Bakke —a program that "did not contemplate that any single characteristic automatically ensured a specific and identifiable contribution to a university's diversity " The result was a policy that did not "offer applicants the individualized selection process described in Harvard's example," and that could consequently not pass strict scrutiny  On that point Justice O'Connor also agreed  As she explained in supplying her decisive fifth vote, the undergraduate policy simply did not "enable[] admissions officers to make nuanced judgments with respect to the contributions each applicant is likely to make to the diversity of the incoming class," unlike the Law School's more holistic policy  This was true even though the undergraduate policy "assign[ed] 20 points to some 'soft' variables other than race," such as "leadership and service, personal achievement, and geographic diversity " None of that, in Justice O'Connor's view, could counteract the more problematic effect of those factors' being "capped at much lower levels," so that "even the most outstanding national high school leader could never receive more than five points for his or her accomplishments—a mere quarter of the points automatically assigned to an underrepresented minority solely based on the fact of his or her race " That weighting, though not problematic in all cases, had all but ensured there "that the diversity contributions of applicants [could not] be individually assessed " A thumb pressed that heavily on the racial scale, Justice O'Connor concluded, came too close to the "nonindividualized, mechanical" balancing condemned by Bakke to survive strict scrutiny  Despite their contrasting results, Gratz and Grutter gestured at several basic criteria by which to assess a university's race-conscious admissions policy  Those criteria, as the U S  Court of Appeals for the Ninth Circuit later described them, could be summed up in "five hallmarks of a narrowly tailored affirmative action plan " And all five can be traced in one way or another to Justice Powell's analysis of the Harvard plan  1  No Quotas  Perhaps the clearest violation of the requirement that a policy be narrowly tailored is the use of racial quotas  As Justice O'Connor explained in Grutter , a "'quota' is a program in which a certain fixed number or proportion of opportunities are reserved exclusively for certain minority groups," consequently "insulat[ing] the individual [applicant] from comparison with all other candidates for the available seats " And as Justice Powell emphasized in Bakke , and as has been consistently reaffirmed by the Court since, "[t]o be narrowly tailored, a race-conscious admissions program cannot use a quota system " This ban on quotas therefore precludes the use of a rigid set-aside like the one challenged in Bakke   And it likewise rules out the sort of "mechanical," automatic points system that was once in place at the University of Michigan's undergraduate college and was later invalidated in Gratz   2  Individualized Consideration  The flip side of the Court's refusal to accept racial quotas has been its insistence on individualizing the consideration of applicants  As Justice Kennedy reaffirmed in Fisher I , echoing Justice Powell's description of the Harvard plan in Bakke , an appropriately tailored program "must 'remain flexible enough to ensure that each applicant is evaluated as an individual and not in a way that makes an applicant's race or ethnicity the defining feature of his or her application '" And as the Court suggested in Gratz and Grutter , an acceptable plan will therefore engage in a "highly individualized, holistic review of each applicant's file, giving serious consideration to all the ways an applicant might contribute to a diverse educational environment " Such review allows "the use of race as one of many 'plus factors' in an admissions program," like in the University of Michigan Law School's policy upheld in Grutter   It also appears to bar a school from "automatically award[ing] points to applicants from certain racial minorities" as an effectively decisive factor, as it became under the university's undergraduate policy  3  Serious, Good-Faith Consideration of Race-Neutral or More Flexible Alternatives  Neither of these two criteria, however, implies that a university must exhaust "every conceivable race-neutral alternative" before turning to a race-conscious policy  Instead, a university need only provide evidence that it undertook "serious, good faith consideration of workable race-neutral alternatives" before resorting to its choice of a race-conscious plan, but that those alternatives either did not suffice to meet its approved educational goals or would have required some sacrifice of its "reputation for academic excellence " The same holds true, moreover, of more flexible race-conscious alternatives  Thus Justice Powell explained in Bakke that the Medical School's program was not narrowly tailored when the school could have adopted the more individualized, holistic program then in use at Harvard, an option the Medical School apparently did not consider  4  No Undue Harm  Even though the Court has allowed the use of race-conscious admissions policies under the exacting standard of strict scrutiny, it has also long "acknowledge[d] that 'there are serious problems of justice connected with the idea of preference itself '" In Grutter , Justice O'Connor drew another corollary from that apparent discomfort with racial preferences  "[A] race-conscious admissions program," she explained, must "not unduly harm members of any racial group " What this corollary means more specifically remains unclear; so far it has received only passing attention from the Court  At the least, Justice O'Connor suggested, a race-conscious admissions policy must not "unduly burden individuals who are not members of the favored racial and ethnic groups " And in Grutter , Justice O'Connor put more flesh on that analysis: an affirmative action policy that closely resembled the Harvard plan, she suggested, would not "unduly harm" other applicants  It remains to be seen, however, whether this principle might take on new life in the Court's review of other plans  5  Ongoing Review  In Grutter , Justice O'Connor also drew a fifth and final corollary from the basic premise that the Fourteenth Amendment was meant "to do away with all governmentally imposed discrimination based on race " "[R]ace-conscious admissions policies," she concluded, "must be limited in time " This requirement, Justice O'Connor explained for the Court, reflected a consideration apparently unique to racial classifications: "however compelling their goals, [they] are potentially so dangerous that they may be employed no more broadly than the interest demands " Doctrinally, this meant there could be no "permanent justification" for race-conscious admissions policies in higher education; sooner or later they had to end, as the university conceded in its briefing  Practically, this "logical end point" could come in one of several ways  It could take the form of an explicit "durational limit," such as a sunset provision  Or it could arrive as a result of "periodic reviews to determine whether racial preferences are still necessary to achieve student body diversity " But, however a university chooses to pursue that end, it has an "ongoing obligation to engage in constant deliberation and continued reflection regarding its admissions policies" and the role race plays in them, or whether it should continue to play one at all  For several Justices this ongoing obligation of review also pointed to something more definite—an expiration date, when "the use of racial preferences will no longer be necessary to further [the school's] interest" in student body diversity  Looking back over the quarter-century since Bakke , Justice O'Connor "expect[ed]" that day to come twenty-five years after casting her deciding votes in Gratz and Grutter —ten years from this writing  What exactly this meant, as either a practical or doctrinal matter, also remains unclear  Indeed, even then several of her fellow Justices seemed less sure, or simply unsure, what to make of that unusually specific constitutional deadline  But with six Justices having since departed the Court, Justices O'Connor and Kennedy included, it remains to be seen whether in the next ten years race-conscious admissions policies will reach this foreordained "logical end point " What seems clear for now, however, is that the Harvard plan described in Bakke remains the Court's working model of a constitutionally satisfactory race-conscious admissions policy  And that, as the Court has consistently said since, is a policy capable of achieving the diversity "essential" to the life of a modern university, while still "treat[ing] each applicant as an individual " Race has come to play two major doctrinal roles in higher education today, mirroring the two senses of "affirmative action" discussed in this report: the mandatory role, rooted in the affirmative obligation states have to eliminate the vestiges of de jure segregation, and the voluntary role, particularly in admissions decisions at selective colleges and universities  In the context of higher education, the Court has so far considered these two forms of "affirmative action" only in relation to public universities, and then primarily as a matter of constitutional law, under the Fourteenth Amendment's Equal Protection Clause  But many of those cases have also involved claims brought under Title VI of the Civil Rights Act of 1964 (Title VI or the Act)  And while the Court has read Title VI's protections to overlap with the Equal Protection Clause, Congress still has a significant say over the substantive scope of Title VI as well as its enforcement  Title VI generally protects participants in federally funded "program[s] or activit[ies]" from discrimination based on their "race, color, or national origin " To ensure that statutory right, the Act grants all federal funding agencies the authority to issue implementing regulations, and the power to enforce the regulations they issue  In practice, much of the interpretive authority falls to the U S  Department of Justice (DOJ), and for educational programs, the U S  Department of Education (ED)  Both DOJ and ED have also established their own processes for receiving and investigating complaints of suspected Title VI violations  ED, meanwhile, has also issued its own set of rules to govern the federal education dollars it disburses each year, reaching some 4,700 colleges and universities  Every agency that awards federal funds—ED included—has the authority not just to issue implementing regulations but to enforce those rules against noncompliant recipients, including through an investigation that may, upon a finding of noncompliance, result in the termination, suspension, or refusal to grant federal funds  Thus, for example, where ED finds a school in violation of Title VI or its implementing regulations the department may seek to cut off federal funding through an "administrative fund termination proceeding," as it has in at least some cases  And since the passage of the Civil Rights Restoration Act of 1987, the courts have read the scope of liability under Title VI broadly  With respect to the termination of funds, a Title VI violation in one program at a college or university could therefore jeopardize funding for the institution as a whole  Withdrawing funds may be the ultimate means of enforcing Title VI, but it is far from exclusive  DOJ, for its part, has also sought to achieve compliance through the federal courts, intervening in some private suits alleging Title VI violations and otherwise representing executive branch agencies, such as ED, in lawsuits seeking enforcement of Title VI  DOJ has participated in cases challenging practices of formerly de jure segregated public university systems as well as in settlements resolving such Fordice -related claims  DOJ has also taken a position in cases challenging affirmative action admissions policies, most recently in the ongoing litigation surrounding Harvard College's admissions policies  ED has ventured into this area as well, having recently opened investigations into the admissions decisions at several prominent private universities  Congress continues to have considerable say over how Title VI works—at least within the parameters of the Supreme Court's equal protection jurisprudence  Perhaps the most direct way of doing so is by amendment  As a general matter, Congress could revise Title VI in one of two directions, to make the statute either (1) more restrictive than the Court's current Equal Protection jurisprudence or (2) expressly permissive of race-conscious measures that the Court has upheld or has thus far not addressed  In the more restrictive direction, Congress could prohibit recipients of federal funds from using voluntary race-conscious measures at all—a result that four Justices in Bakke argued Title VI already requires, but which the Court has so far not embraced  A statutory revision of that kind would also implicitly reject the Harvard Plan discussed in Bakke , by excluding race as a permissible factor in admissions decisions at the many universities subject to Title VI, including the many private universities that receive federal funds  And, consequently, an amendment along these lines would make unlawful the type of admissions policies that the Court has approved under the Equal Protection Clause, like those at issue in Grutter and Fisher II   On the other hand, Congress could expressly open other avenues for effectuating Title VI's antidiscrimination mandate  This could include incorporating a private right of action to bring suit under Title VI, which, at present, is an implied right with no statutorily defined remedies  More consequentially, Congress could also amend Title VI to provide for disparate impact liability—that is, a Title VI violation based on a funding recipient's use of certain policies or practices that disproportionately and negatively impact members of a protected class, as already exists under Title VII of the same Act  A provision addressing disparate impact liability—either its availability or foreclosure under Title VI—would resolve a significant and ongoing debate on the issue  Such an addition would also be one way of clarifying whether Congress does in fact intend for Title VI to be read coextensively with the Equal Protection Clause  Beyond legislative amendments, Congress also exercises oversight over the agencies charged with carrying out Title VI's antidiscrimination mandate  As discussed earlier, DOJ and ED are primarily responsible for enforcing Title VI in educational programs  For its part, ED investigates and seeks compliance through its Office for Civil Rights, while the Educational Opportunities Section of the Department of Justice's (DOJ's) Civil Rights Division typically enforces Title VI in educational programs for the department  Both offices maintain public archives documenting their past and current investigations, as well as wider-ranging reports detailing their enforcement priorities and investigatory procedures  And because Title VI applies to a wide variety of entities that receive federal financial assistance, not just colleges and universities, DOJ also publishes news and updates on Title VI enforcement activity in other programmatic areas, from agencies across the federal government  Race has come to play two major doctrinal roles in higher education today, reflecting the two senses of "affirmative action" discussed in this report  "Affirmative action" in its original sense grew out of the affirmative obligation imposed on the states by the Equal Protection Clause to eliminate the vestiges of de jure segregation from their public schools  And in that sense, "affirmative action" involves the mandatory use of race-conscious measures in higher education to right the enduring wrongs of state-sanctioned segregation  But "affirmative action" has also come to refer to race-conscious policies outside this de jure context—policies voluntarily adopted by institutions to help racial minorities overcome the effects of their earlier exclusion  In higher education, none has been more salient—or stirred more debate—than the race-conscious admissions policies that colleges and universities across the country have used to diversify their student bodies  Thus far, remedial measures addressing de jure segregation, and voluntary measures designed to promote student-body diversity, have been the only race-conscious measures that the Court has approved under the Equal Protection Clause  And both remain areas of active litigation and administrative enforcement  Over the years, however, the Court has made it clear that it will subject voluntary "affirmative action" policies to especially close scrutiny, approving them only when they can be shown to be narrowly tailored to serve compelling educational goals  It has approved such polices twice already, most recently in 2016  Still, several Justices have suggested that the rationales supporting these voluntary race-conscious measures will one day run out  But for the time being, at least, these two lines of authority nevertheless provide a place for affirmative action in higher education today  This authority, however, leaves questions as of yet unexplored  It appears to be an open question, for example, whether a public institution of higher education can cite its own history of intentional exclusion, or else its "past discrimination," as a basis for adopting a race-conscious admissions policy, among other measures  Whether—and how—the courts might assess such untested arguments would likely turn on a range of factors, including the further development of the two lines of authority addressed in this report  Regardless of those and other possible developments, however, Congress still has a significant say in in this area, through its authority not just to revise Title VI but to oversee the Act's enforcement 

ground_truth: VA provides services and benefits to veterans through hospitals and other facilities nationwide. Misconduct by VA employees can have serious consequences for some veterans, including poor quality of care. GAO was asked to review employee misconduct across VA. This report reviews the extent to which VA (1) collects reliable information associated with employee misconduct and disciplinary actions, (2) adheres to documentation-retention procedures when adjudicating cases of employee misconduct, (3) ensures allegations of misconduct involving senior officials are reviewed according to VA investigative standards and these officials are held accountable, and (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA. GAO analyzed 12 information systems across VA to assess the reliability of misconduct data, examined a stratified random sample of 544 misconduct cases from 2009 through 2015, analyzed data and reviewed cases pertaining to senior officials involved in misconduct, reviewed procedures pertaining to whistle-blower investigations, and examined a nongeneralizable sample of whistle-blower disclosures from 2010 to 2014. The Department of Veterans Affairs (VA) collects data related to employee misconduct and disciplinary actions, but fragmentation and data-reliability issues impede department-wide analysis of those data. VA maintains six information systems that include partial data related to employee misconduct. For example, VA's Personnel and Accounting Integrated Data system collects information on disciplinary actions that affect employee leave and pay, but the system does not collect information on other types of disciplinary actions. The system also does not collect information such as the offense or date of occurrence. GAO also identified six other information systems that various VA administrations and program offices use to collect specific information regarding their respective employees' misconduct and disciplinary actions. GAO's analysis of all 12 information systems found data-reliability issues—such as missing data, lack of identifiers, and lack of standardization among fields. Without collecting reliable misconduct and disciplinary action data on all cases department-wide, VA's reporting and decision making on misconduct are impaired. VA inconsistently adhered to its guidance for documentation retention when adjudicating misconduct allegations, based on GAO's review of a generalizable sample of 544 out of 23,622 misconduct case files associated with employee disciplinary actions affecting employee pay. GAO estimates that VA would not be able to account for approximately 1,800 case files. Further, GAO estimates that approximately 3,600 of the files did not contain required documentation that employees were adequately informed of their rights during adjudication procedures—such as their entitlement to be represented by an attorney. The absence of files and associated documentation suggests that individuals may not have always received fair and reasonable due process as allegations of misconduct were adjudicated. Nevertheless, VA's Office of Human Resource Management does not regularly assess the extent to which files and documentation are retained consistently with applicable requirements. VA did not consistently ensure that allegations of misconduct involving senior officials were reviewed according to investigative standards and these officials were held accountable. For example, based on a review of 23 cases of alleged misconduct by senior officials that the VA Office of Inspector General (OIG) referred to VA facility and program offices for additional investigation, GAO found VA frequently did not include sufficient documentation for its findings, or provide a timely response to the OIG. In addition, VA was unable to produce any documentation used to close 2 cases. Further, OIG policy does not require the OIG to verify the completeness of investigations, which would help ensure that facility and program offices had met the requirements for investigating allegations of misconduct. Regarding senior officials, VA did not always take necessary measures to ensure they were held accountable for substantiated misconduct. As the figure below shows, GAO found that the disciplinary action proposed was not taken for 5 of 17 senior officials with substantiated misconduct. As a result of June 2017 legislation, a new office within VA—the Office of Accountability and Whistleblower Protection—will be responsible for receiving and investigating allegations of misconduct involving senior officials. VA has procedures for investigating whistle-blower complaints, but the procedures allow the program office or facility where a whistle-blower has reported misconduct to conduct the investigation. According to the OIG, it has the option of investigating allegations of misconduct, or exercising a “right of first refusal” whereby it refers allegations of misconduct to the VA facility or program office where the allegation originated. VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence. As a result, GAO found instances where managers investigated themselves for misconduct, presenting a conflict of interest. Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014. Additionally, GAO's interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring. These whistle-blowers alleged that managers in their chain of command took several untraceable actions to retaliate against the whistle-blowers, such as being denied access to computer equipment necessary to complete assignments. GAO makes numerous recommendations to VA to help enhance its ability to address misconduct issues (several of the recommendations are detailed on the following page). GAO recommends, among other things, that the Secretary of Veterans Affairs develop and implement guidance to collect complete and reliable misconduct and disciplinary-action data department-wide; such guidance should include direction and procedures on addressing blank fields, lack of personnel identifiers, and standardization among fields; direct applicable facility and program offices to adhere to VA's policies regarding misconduct adjudication documentation; direct the Office of Human Resource Management to routinely assess the extent to which misconduct-related files and documents are retained consistently with applicable requirements; direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the required elements have been addressed; direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented; and develop procedures to ensure (1) whistle-blower investigations are reviewed by an official independent of and at least one level above the individual involved in the allegation, and (2) VA employees who report wrongdoing are treated fairly and protected against retaliation. GAO also recommends, among other things, that the VA OIG revise its policy and require verification of evidence produced in senior-official case referrals. VA concurred with nine recommendations and partially concurred with five. In response, GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted.