IC IG CPD – ERP Intake Form Rev: March 2022

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: 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 Office of the Inspector General (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.

UNCLASSIFIED SUBMISSION ONLY

External Review Panel Request Form

You have 60 calendar days after exhausting your agency’s or department's review process and receiving the final 

written decision on your reprisal allegations to request further review by an External Review Panel (ERP). For 

additional regarding the ERP process, please visit www.dni.gov/ICIG-Whistleblower.

(*) Required Information

1. Contact information of person requesting External Review 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:
EXTERNAL REVIEW PANEL (ERP)

UNCLASSIFIED REQUEST FORM

Page | 2 IC IG CPD – ERP Intake Form Rev: March 2022

2. Your Status*

Select one, or enter your status if not listed.

Other:

Your position Title Series Grade

3. Your Agency or Employer*

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

Other:

4. Do you have legal or other representation for this request? Yes(Please complete SECTION 4a) 

No 

SECTION 4a – Legal Representation Information: 

Name of Representative*

Type of Representation Legal Other

Notice of Representation (Attached) Y es No

Mailing Address

Telephone Number (Primary)

Telephone Number (Secondary)

Fax Number

Email Address(es)*

Primary: Secondary:
EXTERNAL REVIEW PANEL (ERP)

UNCLASSIFIED REQUEST FORM

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PART 2: DETAILS OF YOUR REQUEST FOR EXTERNAL REVIEW

1. Please provide a summary of your protected disclosure(s) below. If necessary, please continue on a second

sheet of paper.

Do not include classified information on this form.

Attachments: Yes No Total Pages Attached:

2. Please identify the adverse personnel action or adverse action affecting security clearance, including dates,

times, locations, and the person (s) who took the action or who made the threat of any such action.

Do not include classified information on this form.

3. Please describe how the reprisal allegations you are making are linked to your protected disclosure(s).

Do not include classified information on this form.
EXTERNAL REVIEW PANEL (ERP)

UNCLASSIFIED REQUEST FORM

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

4. Please provide a brief summary of the final decision of the agency whose decision you are now seeking to have

reviewed.

Do not include classified information on this form.

5. Please state the reason(s) why you are seeking an external review of the final agency decision regarding your

reprisal allegations and identify any factual, legal, or procedural errors as your basis for the requested external

review. If necessary, please continue on a second sheet of paper.

Do not include classified information on this form.

Attachments: Yes No Total Pages Attached:
EXTERNAL REVIEW PANEL (ERP)

UNCLASSIFIED REQUEST FORM

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

PART 3: 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 4: ADDITIONAL DOCUMENT SUBMISSION

1. I am submitting additional documents* Yes No

2. The attached documents are UNCLASSIFIED* Yes No

Do not include classified information. 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:
EXTERNAL REVIEW PANEL (ERP)

UNCLASSIFIED REQUEST FORM

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PART 5: CERTIFICATION AND SIGNATURE

By signing below, you acknowledge the following:

*I understand that in handling my request the IC IG will maintain the confidentiality of my identity as

required by law. However, I understand the disclosure of my name outside of the IC IG will be necessary in

order to fully investigate or take other appropriate official action on the allegations contained within my

request for an external review.

*I understand that in order to make an initial assessment of my case, the IC IG will request official records

about me from other agencies, including but not limited to my home agency and any agency that

investigated my claims.

*I understand that if an ERP is convened, my information will be shared with other Offices of Inspector

General as needed in order to carry out the responsibilities of the IC IG under PPD-19, Section C and 50

U.S.C. §§ 3033 and 3236.

*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