UNCLASSIFIED SUBMISSION ONLY 

IC IG CPD – Hotline Intake Form Rev: January 2024 

IC Whistleblower Protection Act Disclosure Form

The Office of the Inspector General of the Intelligence Community (IC IG) Center for Protected Disclosures, through

the IC IG Hotline Program, receives and processes whistleblower complaints, to include disclosures pursuant to the 

Intelligence Community Whistleblower Protection Act (ICWPA) 50 U.S.C. § 3033(k)(5) and 5 U.S.C. app. § 8H. The 

ICWPA is the lawful mechanism for Intelligence Community employees and contractors to disclose matters of 

“urgent concern” to the congressional intelligence committees, as defined by 50 U.S.C. § 3033(k)(5)(A). For 

additional information regarding ICWPA disclosure, please visit https://www.dni.gov/ICIG-Whistleblower. 

☐

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.

PART 1: BASIC ICWPA CRITERIA

(*) Required Information

1. Current Status* See 50 U.S.C. § 3003(4) for the definition of “intelligence community”

☐ Employee of an element of the Intelligence Community.

☐ Employee assigned or detailed to an element of the Intelligence Community.

☐ Employee of a contractor to the Intelligence Community.

☐ Not an employee of the Intelligence Community or an employee of a contractor to the Intelligence

Community. STOP and complete the IC IG Complaint Intake Form, or contact your former agency Office

of Inspector General or the Office of Special Counsel for information on making a disclosure.

2. Do you intend to report a matter of urgent concern complaint to Congress pursuant to

50 U.S.C. § 3033(k)(5)?

☐ Yes

☐ No

3. Please identify the type of urgent concern you are reporting (check all that apply).

☐

A serious or flagrant problem, abuse, violation of law or Executive Order, or deficiency relating to the 

funding, administration, or operations of an intelligence activity of the Federal Government that is a matter 

of national security; and not a difference of opinion concerning public policy matters. STOP and contact 

the IC IG Hotline (855-731-3260) to determine appropriate submission procedures for disclosures 

containing classified information. 

☐ A false statement to Congress, or a willful withholding from Congress, on an issue of material fact relating 

to the funding, administration, or operation of an intelligence activity. 

☐

An action, including a personnel action described in section 2302(a)(2)(A) of Title 5, constituting reprisal or 

threat of reprisal prohibited under subsection(g)(3)(B) of this section in response to an employee reporting 

an urgent concern in accordance with this section. 
ICWPA DISCLOSURE 

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Page | 2 IC IG CPD – Hotline Intake Form Rev: January 2024 

PART 2 – CONFIDENTIALITY NOTICE 

(*) 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 disclosure cannot be processed without you selecting one of the boxes below*

☐ WAIVE CONFIDENTIALITY. By checking this box, I choose to waive confidentiality, and 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 address the 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 protections is available at the IC IG website.

☐ CONFIDENTIALITY. By checking this box, I choose to identify myself for purposes of making this submission,

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.

PART 3: 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 requests for 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.

1. Contact Information of person making an “urgent concern” disclosure

(*) Required Information. Do not include classified information on this form.

First Name* Middle Name Last Name* 

Full Mailing Address 

Telephone Number (Primary) 

Telephone Number (Secondary) 

Email Address(es)* 

Primary: Secondary:

Your position Title Series Grade 

Indicate Best Time to Call
ICWPA DISCLOSURE 

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Page | 3 IC IG CPD – Hotline Intake Form Rev: January 2024 

☐ Yes (Please complete SECTION 2a)

☐ No

PART 4: DETAILS OF YOUR DISCLOSURE

1. Please describe the matter of urgent concern that you are disclosing, indicating how the specific alleged

wrongdoing fits within the urgent concern type(s) that you checked in Part 1, item 3. Be as specific as possible

about dates, locations, and the identities and positions of all persons named. Your ability to succinctly identify

the issue and supporting facts will assist in the processing of your disclosure. If necessary, please continue on

a separate sheet of paper.

Attachments: ☐ Yes ☐ No Total Pages Attached:

SECTION 2a – Legal Representation Information:

Name of Representative* 

Type of Representation ☐ Legal ☐ Other

Notice of Representation (Attached) ☐ Yes ☐ No

Mailing Address 

Telephone Number (Primary) 

Email Address(es)* 

Primary: Secondary:

2. Your Agency or Employer*

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

Other:

3. Do you have legal or other representation for this request?

Select
ICWPA DISCLOSURE 

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Page | 4 IC IG CPD – Hotline Intake Form Rev: January 2024 

PART 5: OTHER ACTIONS YOU ARE TAKING

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.

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

1b. If yes, which organization(s)/agency(ies)? 

1c. When did you report? 

1d. What is the status of the complaint? ☐ Open ☐ Under investigation ☐ Closed ☐ Unknown

If you have received any responses from those entity(ies), please provide copies. 

PART 6: ADDITIONAL DOCUMENT SUBMISSION

1. I am submitting additional documents* ☐ Yes ☐ No

2. The attached documents are UNCLASSIFIED* ☐ Yes ☐ No

If no, contact the IC IG Hotline for guidance on how to submit a classified complaint. 

3. I will submit supporting documents by: ☐ Email ☐ Mail ☐ Fax

Total pages attached: 

2. Please identify the U.S. Government department or agency involved in your disclosure. 

Choose one, or enter the department/agency if not listed. 

Other

3. Please identify the organizational unit of the department or agency involved in your disclosure. 

Select
ICWPA DISCLOSURE 

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Page | 5 IC IG CPD – Hotline Intake Form Rev: January 2024 

PART 7: CERTIFICATION AND SIGNATURE

By signing below, you acknowledge the following: 

☐

*I understand that in handling my disclosure, the IC IG shall not disclose my identity without my consent,

unless the IC IG determines that such disclosure is unavoidable during the course of the investigation or

the disclosure is made to an official of the Department of Justice responsible for determining whether a

prosecution should be undertaken.

☐ *I understand that 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