IC IG CPD – Hotline Intake Form Rev: March 2022

PART 1: CONFIDENTIALITY NOTICE

UNCLASSIFIED SUBMISSION ONLY

Complaint Intake Form

The Office of the Inspector General of the Intelligence Community (IC IG) is authorized to receive and investigate 

complaints or information from any person concerning the existence of an activity within the authorities and 

responsibilities of the Director of National Intelligence.

If you are making a disclosure pursuant to the Intelligence Community Whistleblower Protection 

Act (ICWPA) 50 U.S.C. § 3033(k)(5), please visit the IC IG Hotline webpage for additional 

information and complete an ICWPA Disclosure Form.

If you are requesting a review by an External ReviewPanel (ERP), please visit the IC IG Hotline

webpage for additional information and complete the ERP Form.

I affirm that my submission, including any attachments, does not include classified information. If your 

submission, including any attachments, may contain CLASSIFIED INFORMATION, please contact the IC IG

HOTLINE (Open: 855-731-3260  Secure: 933-2800) to determine appropriate submission procedures.

(*) Required Information 

1. By selecting one of the following options below you acknowledge that you have read and understand the

choice you are making. Your submission cannot be processed without you selecting one of the boxes below.*

WAIVE CONFIDENTIALITY. By checking this box, I choose to waive confidentiality, and I give consent for the IC IG

Hotline to release my identity outside the IC IG on a need-to-know basis. By waiving confidentiality, I understand

that the IC IG can assist me and addressthe concerns that I raised. I also understand that there are legal authorities

that generally prohibit retaliation against those who lawfully report alleged wrongdoing to the IC IG. More

information about these legal protectionsis available at the IC IG website.

CONFIDENTIALITY. By checking this box, I choose to identify myself for purposes of making thissubmission, but I DO

NOT give consent to the IC IG Hotline to provide my name and contact information outside the IC IG, except as

required by law. I understand that the IC IG will not disclose my identity without my consent, unless the IC IG

determines that such a disclosure is unavoidable during the course of an investigation, or the disclosure is made to

an official of the Department of Justice responsible for determining whether a prosecution should be undertaken.

ANONYMOUS. By checking this box, I choose to submit my complaint or information anonymously. I understand

choosing anonymity may limit the IC IG’s ability to take appropriate steps to address the concerns that I have raised,

including the ability for IC IG to contact me to obtain further information.
REPORT OF FRAUD, WASTE, AND ABUSE

UNCLASSIFIED INTAKE FORM

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IC IG CPD – Hotline Intake Form Rev: March 2022

Other:

Other:

PART 2: YOUR INFORMATION

DATA REQUIRED BY THE PRIVACY ACT OF 1974

PURPOSE: To obtain sufficient information to inquire into matters presented and to provide appropriate responses, 

referrals, or inquiries, where deemed appropriate.

ROUTINE USES: Information is used for official purposes within the Office of the Director of National Intelligence (ODNI) 

and the IC IG; to answer complaints or respond to requestsfor assistance, advice, or information; by Members of Congress 

and other government agencies when determined by the IC IG to be in the best interest of the Intelligence Community.

(*) Required Information 

1. Contact information of person requesting Hotline Intake to the IC IG

Contact Information Do not include classified information on this form.

Prefix (Mr., Mrs., Ms., Rank, or Title)

First Name* Middle Name Last Name*

Mailing Address

Telephone Number (Primary)

Telephone Number (Secondary)

Fax Number

Email Address(es)*

Primary: Secondary:

2. Your Status*

Select

Your position Title Series Grade

3. Your Agency or Employer*

Choose one, or enter your agency/employer if not listed

Select
REPORT OF FRAUD, WASTE, AND ABUSE

UNCLASSIFIED INTAKE FORM

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IC IG CPD – Hotline Intake Form Rev: March 2022

Select On

PART 3: ALLEGATION DETAILS

1. I have knowledge of the information I am disclosing based on (check all that apply):

Personal and/or direct knowledge of the incident

What other individuals have told me about the incident

Othersource(s) (please explain):

2. What is the topic of your complaint(s)?*

Select all that apply, or enter your topic if not listed.

Other:

3. Where did the incident(s) occur? Do not include classified information on this form.

Choose one, or enter the location if not listed.

Other:

4. When did you become aware of the incident(s)?

Do not include classified information on this form.
REPORT OF FRAUD, WASTE, AND ABUSE

UNCLASSIFIED INTAKE FORM

Page | 4 IC IG CPD – Hotline Intake Form Rev: March 2022

5. Identify the person(s) who you believe carried out the alleged wrongdoing.

Do not include classified information on this form.

Person 1 Person 2 Person 3 

Name

Middle Name

Last Name

Title

Status

Other

Agency

Other

6. Identify the person(s) who you believe witnessed the alleged wrongdoing.

Do not include classified information on this form.

Witness 1 Witness 2 Witness 3 

Name

Middle Name

Last Name

Title

Status

Other

Agency

Other

Phone Number

Email Address

7. How do you believe the IC IG can assist you?
REPORT OF FRAUD, WASTE, AND ABUSE

UNCLASSIFIED INTAKE FORM

Page | 5 IC IG CPD – Hotline Intake Form Rev: March 2022

Do not include classified information on this form.

8. Prepare a summary of the facts describing the incident(s).

Please avoid including opinions and/orspeculation. Consider the following to help guide your narrative:

• What are the facts?

• Who is involved?

• When did it occur?

• Where did it happen?

• What, based on the above, is the violation of law, rule, or regulation; gross mismanagement; a gross waste of

funds; an abuse of authority; or, a substantial and specific danger to public health or safety?

• What is the classification level of the information involved?
REPORT OF FRAUD, WASTE, AND ABUSE

UNCLASSIFIED INTAKE FORM

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Please indicate if you have filed your complaint with any other entity, including other Inspector General Offices, 

and/or Members of Congress. If you have contacted other entities, clearly identify the agency, office, or command, 

and provide your understanding of the current status of your matter.

1. Have you reported this matter to any other organization(s)/agency(ies)?* Yes No

2. If yes, which organization(s)/agency(ies)?

3. When did you report?

4. What is the status of the complaint? Open Under investigation Closed Unknown

If you have received anywritten responsesfrom those entity(ies), please provide copies.

PART 5: ADDITIONAL DOCUMENT SUBMISSION

1. I amsubmitting additional documents* Yes No

2. The attached documents are UNCLASSIFIED* Yes No

Do notinclude classified information on thisform. Contactthe IC IGHotline for guidance on howto submit a classified 

complaint.

3. I willsubmitsupporting documents by: Email Mail Fax

Total pages attached:

PART 6: CERTIFICATION AND SIGNATURE

By signing below, you acknowledge the following:

*I understand that, if warranted, this form and any supporting documents transmitted to the IC IG will

undergo classification review.

*I certify that all of the statements made in this complaint (including any additional documents or

continuation pages) are true, complete, and correct, to the best of my knowledge and belief. I understand

that, pursuant to 18 U.S.C. § 1001, knowingly and willfully making a false statement or concealing a material

fact in any matter within the jurisdiction of the Executive Branch, including the IC IG, is a criminal offense.

Signature Date

(Do not include your signature if you selected “anonymous” in Part 1.)

PART 4: OTHER ACTIONS YOU ARE TAKING