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Office of the Inspector General of the Intelligence Community

Intelligence Community Whistleblower and Source Protection Program


Urgent Concern Disclosure Form (ICWSP Form 401)

INFORMATION ABOUT FILING A DISCLOSURE OF URGENT CONCERN


PURSUANT TO THE
INTELLIGENCE COMMUNITY WHISTLEBLOWER PROTECTION ACT (ICWPA)

Background Information on ICWPA Process

URGENT CONCERN DISCLOSURE INFORMATION


The Office of the Inspector General of the Intelligence Community (IC IG), ICWSP Program manages the Intelligence
Community Whistleblower Protection Act (ICWPA) disclosure process. The ICWPA is the lawful mechanism for
Intelligence Community employees and contractors to disclose matters of “urgent concern” to congressional
intelligence committees. The ICWPA defines an “urgent concern” as:
 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 involving classified information, but does
not include differences of opinion concerning public policy matters
 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 personnel action described in 5 U.S.C. § 2302(a)(2)(A) of Title 5, constituting reprisal or
threat of reprisal prohibited under section 7(c) of the Inspector General Act of 1978, as amended, in
response to an employee reporting an urgent concern
The IC IG receives and processes ICWPA urgent concern disclosures from employees (civilian, military or contractor)
of the Intelligence Community, as defined by 50 U.S.C. § 3003(4). Individuals who are not employees of the
Intelligence Community and desire to contact Congress with a disclosure should contact their agency Office of
Inspector General or the Office of Special Counsel for information on congressional disclosures.
If your disclosure meets the ICWPA’s thresholds and is deemed a “credible” urgent concern, your urgent concern
will be forwarded to the Director of National Intelligence for review prior to transmission to the congressional
intelligence committees. If the disclosure does not meet the ICWPA requirements, you will be informed of this
determination and provided information on other offices available for receiving the disclosure or the process and
procedures to contact the congressional intelligence committees regarding a non-urgent disclosure in accordance
with appropriate security practices.
If your urgent concern is determined to be credible, the process for transmission to the congressional intelligence
committees is a minimum of 21 calendar days. Should the congressional intelligence committee(s) require additional
information regarding your urgent concern disclosure, the ICWPA program can provide additional assistance in
understanding the security practices and procedures applicable to your communications with the congressional
intelligence committee(s).
Please note that the IC IG ICWSP program manages the ICWPA process for congressional disclosures. While the IC IG
ICWSP program receives and assists with the transmission of these urgent concern disclosures, the IC IG itself may
lack initial jurisdiction to review the underlying facts and circumstances of the urgent concern. Consequently, your
disclosure may be forwarded to a specific agency Office of Inspector General for action, if appropriate. Further, the
IC IG cannot guarantee what action, if any, the intelligence committees of Congress may take regarding your
disclosure.

IC IG ICWSP Form 401 Rev: 24MAY18


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Urgent Concern Disclosure Form
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FIRST-HAND INFORMATION REQUIRED


In order to find an urgent concern “credible,” the IC IG must be in possession of reliable, first-hand information. The
IC IG cannot transmit information via the ICWPA based on an employee’s second-hand knowledge of wrongdoing.
This includes information received from another person, such as when a fellow employee informs you that he/she
witnessed some type of wrongdoing. (Anyone with first-hand knowledge of the allegations may file a disclosure in
writing directly with IC IG.) Similarly, speculation about the existence of wrongdoing does not provide sufficient
legal basis to meet the statutory requirements of the ICWPA. If you think that wrongdoing took place, but can
provide nothing more than second-hand or unsubstantiated assertions, IC IG will not be able to process the
complaint or information for submission as an ICWPA.

ANONYMOUS SOURCES
While IC IG will protect the identity of persons who make disclosures, it cannot consider anonymous disclosures for
ICWPA processing. If a disclosure is filed by an anonymous source, the disclosure will be referred to the Office of
Inspector General in the appropriate agency and the IC IG will take no further action.

CONFIDENTIALITY
While the IC IG cannot action anonymous disclosures, you can request your identity remain confidential. The IC IG
has a statutory duty to protect those who wish to remain confidential. However, requesting confidentiality may
limit the actions the IC IG, other OIGs or Congress may be able to take on your urgent concern disclosure and
disclosure of your identity may become required based on the nature of your allegations.

CREDIBILITY DETERMINATION
The IC IG is responsible for determining whether a complaint or information received is credible for purposes of
submission as an urgent concern. That determination is within the sole discretion of the IC IG and is not subject to
judicial review. Further, while an allegation might constitute a technical disclosure, IC IG will not process minor or
trivial matters as ICWPA submissions.

MATTERS UNDER INVESTIGATION OR REVIEW


The IC IG may, on a case by case basis, not transmit a complaint or information containing allegations of wrongdoing
if the submission reveals information which would otherwise limit or hinder an ongoing investigation, review or
other administrative process. In such cases, the IC IG will notify the intelligence committees of Congress of the
existence of a complaint, and will forward the complaint or information when the ongoing matter has concluded.

SUBMISSION OF URGENT CONCERN DISCLOSURE


This form serves as the formal mechanism for filing an urgent concern disclosure with the IC IG. Completion of the
form will ensure that the IC IG ICWSP has the information required for the review and timely processing of your
disclosure. Failure to complete or submit the form may result in a determination that your disclosure is not credible.
This form should be submitted to the IC IG Hotline for processing. If your answers to any part of the form
are classified, please submit the form via the Classified IC IG Hotline at: icig_hotlineteam_wma@cia.ic.gov.
DO NOT SEND CLASSIFIED INFORMATION TO THE IC IG UNCLASSIFIED HOTLINE
If you have questions regarding the completion of this form or otherwise submitting an ICWPA urgent
concern disclosure, please contact the IC IG Hotline at 855-731-3260 / icighotline@dni.gov or 93-32800 /
icig_hotlineteam_wma@cia.ic.gov.

IC IG ICWSP Form 401 Rev: 24MAY18


Office of the Inspector General of the Intelligence Community
Intelligence Community Whistleblower and Source Protection Program
Urgent Concern Disclosure Form

DISCLOSURE OF URGENT CONCERN FORM


(Please print legibly or type and complete all pertinent items. Enter “N/A” (Not Applicable) or “Unknown” where appropriate.)

Part 1: Background Information

1. Name of person seeking IC IG action (“Complainant”):


Name of Complainant:

2. Contact information:
Address:

Telephone Number(s): ( ) (Primary)


( ) (Secondary)
Fax Number ( )
Email Address(s):

3. Status:
 Current Federal Employee  Applicant for Federal Employment
 Former Federal employee  Current IC Contractor
 Former IC Contractor  Military Service member
 Other (please specify)

4. Current position, title, series, and grade:

5. Please identify any classification concerns regarding your identity or employer:

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6. Agency (employed by, contracting with or detailed to):


 Office of the Director of  Central Intelligence Agency
National Intelligence
 National Security Agency  Defense Intelligence Agency
 National Reconnaissance  National Geospatial Intelligence Agency
Office
 Twenty-Fifth Air Force, U.S. Air  Coast Guard Intelligence, U.S. Coast Guard
Force
 Office of Naval Intelligence,  Marine Corps Intelligence Activity, U.S. Marine
U.S. Navy Corps
 Intelligence and Security  Office of Intelligence and Counterintelligence,
Command, U.S. Army Department of Energy
 Intelligence Branch, Federal  Bureau of Intelligence and Research,
Bureau of Investigation Department of State
 Office of National Security  Office of Intelligence and Analysis, Department
Intelligence, Drug of Homeland Security
Enforcement Agency
 Office of Terrorism and  Other (please specify)
Financial Intelligence,
Department of Treasury

7. Are you currently represented by an attorney for the matter you are disclosing?
Yes  No 
If yes, please complete question 7a and

7a. Legal or other representative information:


Name of Representative:

Type of Representative:  Legal  Other


Notice of Representation attached  Yes  No

7b. Representative’s Contact information:


Mailing Address:

Telephone Number(s): ( ) (Primary)


( ) (Secondary)
Fax Number ( )
Email Address:

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Part 2: Details of Your Disclosure

1. I know about the information I am disclosing here based on (check all that apply):
 I have personal and/or direct knowledge of
events or records involved
 Other employees have told me about events
or records involved
 Other source(s) (please explain)

2. Please identify the classification level of your disclosure:

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

4. Please identify the organizational unit of the department or agency involved:

5. Please identify the type of agency wrongdoing that you are alleging (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 involving classified
information, but does not include differences of opinion concerning public policy matters

 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 personnel action described in section 2302(a)(2)(A) of Title 5, constituting


reprisal or threat of reprisal prohibited under section 7(c) of the Inspector General Act of 1978, as
amended, in response to an employee reporting an urgent concern

 Other (explain below)

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6. Please describe the agency wrongdoing that you are disclosing, indicating how the agency’s actions fit within
the type(s) of wrongdoing that you checked in item 5. (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 you need to continue on a separate sheet of paper,
provide a summary of your disclosure below with the remaining substance on the attached pages.)

Attachments: Y N Total Pages Attached:

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Part 3: Other Actions You Are Taking On Your Disclosure

1. I have previously disclosed (or am disclosing) the violations alleged here to (complete all that apply):

 Inspector General of department / agency involved Date:

 Other office of department / agency involved


Date:
(please specify):

 Department of Justice Date:

 Government Accountability Office (GAO) Date:

 Office of Special Counsel (OSC) Date:

 Other Executive Branch / department / agency Date:


(please specify):

 Congress or congressional committee(s) Date:


(please specify member(s) or committee(s)):

 Media / Advocacy Group(s) / Other Date:


(please specify):

2. If you disclosed the information reported here through any other channel described in question 1, above,
what is the current status of the matter?

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Part 4: Confidentiality Consent and Certification

1. Confidentiality Consent
The IC IG will maintain the confidentiality of your identity where possible. The disclosure of your identity may
become necessary in order to fully investigate, or take other appropriate official action on the allegations
contained within your disclosure or information. Do you consent to the disclosure of your name to others outside
the IC IG, but still within official channels, if it becomes necessary in taking further action on this matter?
I consent to disclosure of my name:

Signature Date

I do not consent to disclosure of my name:

Signature Date

2. Certification
I certify that all of the statements made in this complaint (Including any 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, a false
statement or concealment of a material fact is a criminal offense punishable by a fine of up to $10,000,
imprisonment for up to five years, or both.

Signature Date

IC IG ICWSP Form 401 Rev: 24MAY18