DISCLOSURE OF URGENT CONCERN FORM - UNCLASSIFIED
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ICIG CPD – ICWPA Disclosure Form Rev: August 2019
3. I know about the information I am disclosing here and:
☐ I have direct and personal knowledge
☐ I heard about it from others.
4. Please identify the type of agency wrongdoing 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. STOP and contact the ICIG Hotline
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.
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 ICIG; to answer complaints or respond to requests for assistance, advice, or information; by Members of Congress and
other government agencies when determined by the ICIG to be in the best interest of the Intelligence Community.
5. Contact Information of person making an “urgent concern” disclosure. (Do not include classified
information on this form or attachments.)
Prefix (Mr., Mrs., Ms., Rank, or Title) ___________________
First Name* _______________________________________ Middle Name _____________________________
Last Name* __________________________________________________________________________________
Mailing Address ______________________________________________________________________________
Telephone Number(s)* _________________________________________________________________ (Primary)
Fax Number _________________________________________________________________________
Email Address(es)* _________________________________________________________________________