Initial Complaint & Questionnaire for Whistleblowers InstagramThis field is for validation purposes and should be left unchanged.Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) What is the name of your employer and what is your official job title? Are you a federal employee, prime contractor employee, subcontractor employee, or employee of a NASA grantee (please specify)? If you are a non-federal employee, to the best of your knowledge, has your employer received funds from the Recovery Act?(Required)What is your official chain of supervision? (All supervisors etc., org chart would be helpful.)(Required)Did you report or communicate wrongdoing of any kind to anyone? If so, what was the nature of that wrongdoing (please check all that apply)?(Required) Violation of law, rule, or regulation related to a NASA contract or grant Gross mismanagement of a NASA contract or grant Gross waste of NASA funds Abuse of authority relating to a NASA contract or grant Substantial and specific danger to public health or safety Censorship related to scientific research, analysis, or technology (scientific integrity) None of the above Please describe the nature of the wrongdoing. If you are reporting a "violation of law, rule, or regulation related to a NASA contract or grant," please provide, if you can, the particular law, rule, or regulation violated (by name, subject, and/or citation).(Required)To whom did you report the wrongdoing and when? List each occasion that you reported the alleged wrongdoing and the date that you did so. (These reports of wrongdoing may be considered disclosures.)(Required)Were any harmful actions taken against you after you reported the alleged wrongdoing? If so, what actions were taken against you and when were they taken (month/day/year)?(Required)Who took the above harmful actions against you?(Required)Did the individuals who took the harmful actions against you know about your disclosures or reports of wrongdoing? If so, when and how did they become aware of your disclosures or reports of wrongdoing?(Required)Did anyone else know of your disclosures or reports of wrongdoing? If so, who and when did they become aware?(Required)Are there any witnesses who can corroborate your claims? If so, please list their names and how they can be contacted.(Required)Do you have any records, including documents and emails, that would tend to explain or corroborate your claims? If so, please include them.(Required)Are you aware of any other records (not in your possession) that would tend to corroborate your claims? If so, where might they be obtained?(Required)I, , am filing this complaint and furnishing this information to determine my eligibility for whistleblower protection. Executed on . Confirmation(Required) I declare (or certify, verify, or state) under penalty of perjury that the information provided in this document is true and correctCAPTCHA
