Whistleblower Retaliation Complaint Form | Office of Inspector General, Department of Housing and Urban Development

How did you learn about the HUD OIG Hotline?

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Presenter

Date

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COMPLAINANT INFORMATION

You are a:

Your First Name:

Your Last Name:

Your Address 1:

Your Address 2:

Your City:

Your State:

Your Zip:

Your Phone:

Your Email:

Your Date of Birth:

Preferred Method of Contact

WHEN DID THIS OCCUR?

Specific Date?

Date:

Date Range:

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WITNESS 1

Witness 1 - First Name:

Witness 1 - Last Name:

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Witness 1 - Address 2:

Witness 1 - City:

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WITNESS 2

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Witness 2 - Address 2:

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COVERED STATUS

I. FOR HUD CURRENT/FORMER EMPLOYEES:

State your position at HUD:

Dates of employment at HUD:

II. FOR EMPLOYEES OF HUD CONTRACTORS/SUBCONTRACTOR/GRANTEE/SUBGRANTEE:

State the name of your employer:

State your employer's relationship with HUD programs:

State your position at the employer:

State your dates of employment at the employer:

DISCLOSURE

State the nature of the violation regarding HUD programs that you disclosed:

How did you become aware of the violation?

Provide the name and role (e.g. supervisor, HUD OIG) of the person to whom you made the disclosure, and the date of the disclosure:

RETALIATION

What adverse action occurred against you and when did it occur?

Who took the adverse action identified?

What is the relationship of that person to you?

What did the person who took the action know of your disclosure?

Who are you reporting?

Subject Type:

Name:

First Name:

Last Name:

Address Type:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Email:

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Subject 2

Subject Type:

Subject 2 - Name:

Subject 2 - First Name:

Subject 2 - Last Name:

Subject 2 - Address Type:

Subject 2 - Address 1:

Subject 2 - Address 2:

Subject 2 - City:

Subject 2 - State:

Subject 2 - Zip:

Subject 2 - Phone:

Subject 2 - Email:

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Subject 3

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Subject 3 - Name:

Subject 3 - First Name:

Subject 3 - Last Name:

Subject 3 - Address Type:

Subject 3 - Address 1:

Subject 3 - Address 2:

Subject 3 - City:

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Subject 3 - Zip:

Subject 3 - Phone:

Subject 3 - Email:

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Subject 4

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Subject 4 - Name:

Subject 4 - First Name:

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Subject 4 - Zip:

Subject 4 - Phone:

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Subject 5

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Subject 5 - Name:

Subject 5 - First Name:

Subject 5 - Last Name:

Subject 5 - Address Type:

Subject 5 - Address 1:

Subject 5 - Address 2:

Subject 5 - City:

Subject 5 - State:

Subject 5 - Zip:

Subject 5 - Phone:

Subject 5 - Email:

Add another subject?

Subject 6

Subject Type:

Subject 6 - Name:

Subject 6 - First Name:

Subject 6 - Last Name:

Subject 6 - Address Type:

Subject 6 - Address 1:

Subject 6 - Address 2:

Subject 6 - City:

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OTHER REMEDIES

Have you grieved, appealed, or reported this retaliation through any other process (e.g., EEO, state lawsuit, etc.)? If so, please identify the other action:

Thank you for your complaint, you will be contacted by HUD OIG who will treat your submission with confidentiality.

If you are submitting a report of fraud, waste, abuse, and/or mismanagement to OIG Hotline and have additional documentation to support the allegation please retain the information but annotate in the narrative that you have additional information. If it is determined that the additional information is needed, a HUD OIG employee will be in contact with you to facilitate the transfer of that information.