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EXTERNAL REVIEW PANEL (ERP) REQUEST FORM UNCLASSIFIED Within (Office of Directorate of National Intelligence, Business Transformation Office)

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EXTERNAL REVIEW PANEL (ERP) REQUEST FORM – UNCLASSIFIED
ICIG CPD – ERP Form Rev: August 2019
Within 45 calendar days after exhausting your agency’s or department's review process and receiving the final
written decision on your reprisal allegations, you may request further review by an External Review Panel (ERP)
through the Office of the Inspector General of the Intelligence Community (ICIG). Pursuant to Section C of
Presidential Policy Directive 19 (PPD-19), Protecting Whistleblowers with Access to Classified Information, the ICIG
receives all requests for ERPs to assess whether to convene an ERP. An ERP is not automatic – the decision to grant
review by the ERP is at the sole discretion of the ICIG and is based on the facts and circumstances of the case. For
additional background information, please visit www.dni.gov/ICIG-Whistleblower
.
☐ 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
ICIG
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 ICIG; to answer complaints or respond to requests for assistance, advice, or information; and, by Members of Congress
and other government agencies when determined by the ICIG to be in the best interest of the Intelligence Community.
(*) Required Information
1. Contact Information of person requesting External Review to the ICIG
Prefix (Mr., Mrs., Ms., Rank, or Title) ___________________
First Name* _______________________________________ Middle Name _____________________________
Last Name* __________________________________________________________________________________
Mailing Address ______________________________________________________________________________
____________________________________________________________________________________________
Telephone Number(s)* _________________________________________________________________ (Primary)
_______________________________________________________________ (Secondary)
Fax Number _________________________________________________________________________
Email Address(es)* _________________________________________________________________________
EXTERNAL REVIEW PANEL (ERP) REQUEST FORM - UNCLASSIFIED
Page | 2
ICIG CPD – ERP Form Rev: August 2019
2. Your Status* Select one of the following options, or enter your status if not listed.
Select one
Other: _______________________________________________________________________________________
3. Your current position, title, series, and grade
____________________________________________________________________________________________
4. Your Agency or Employer*
Choose one of the following options, or enter your status if not listed.
Select one
Other: _______________________________________________________________________________________
5. Do you have legal or other representation for this request?
☐ Yes (please complete questions 5a and 5b)
☐ No
5a. Legal or other representative information:
Name of Representative* _____________________________________________________________
Type of Representative: ☐ Legal ☐ Other
Notice of Representation attached: ☐ Yes ☐ No
5b. Legal or other representative’s contact information:
Mailing Address _____________________________________________________________________
___________________________________________________________________________________
Telephone Number(s)* _______________________________________________________ (Primary)
_____________________________________________________ (Secondary)
Fax Number ________________________________________________________________________
Email Address(es)* ___________________________________________________________________
EXTERNAL REVIEW PANEL (ERP) REQUEST FORM - UNCLASSIFIED
Page | 3
ICIG CPD – ERP Form Rev: August 2019
PART 2 - DETAILS OF YOUR REQUEST FOR EXTERNAL REVIEW
6. 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 or attachments.)
7. 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.)
Attachments: ☐ Yes ☐ No
Total Pages Attached: ___________
EXTERNAL REVIEW PANEL (ERP) REQUEST FORM - UNCLASSIFIED
Page | 4
ICIG CPD – ERP Form Rev: August 2019
8. Please describe how the reprisal allegations you are making are linked to your protected disclosure(s).
(Do not include classified information on this form.)
9. 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.)
10. 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 or attachments.)
Attachments:
☐
Yes
☐
No
Total Pages Attached: ___________
EXTERNAL REVIEW PANEL (ERP) REQUEST FORM - UNCLASSIFIED
Page | 5
ICIG CPD – ERP Form Rev: August 2019
PART 3 – OTHER ACTIONS YOU ARE TAKING ON YOUR CASE
Please indicate in this section if you have filed your complaint with any other office, 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.
I have reported this matter to another organization(s)/agency(ies)? * ☐ Yes ☐ No
If yes, which organization(s)/agency(ies)? ______________________________________________________
When did you report this matter?___________________________________________________________
What is the status of that complaint? ☐ Open ☐ Under Investigation ☐ Closed ☐ Unknown
If you have received any responses from those entity(ies), provide copies.
PART 4 – ADDITIONAL DOCUMENT SUBMISSION
DO NOT ATTACH CLASSIFIED INFORMATION TO THIS FORM)
I am submitting additional documents* ☐ Yes ☐ No
The attached documents are UNCLASSIFIED? ☐ Yes ☐ No
If no, contact the ICIG Hotline for guidance on how to submit a classified complaint.
I will submit supporting documents by ☐ Email ☐ Mail ☐ Fax
Total pages attached ______________
EXTERNAL REVIEW PANEL (ERP) REQUEST FORM - UNCLASSIFIED
Page | 6
ICIG CPD – ERP Form Rev: August 2019
PART 5 – CERTIFICATION AND SIGNATURE
By signing below, you acknowledge the following:
☐ *I understand that, in handling my request, the ICIG will maintain the confidentiality of my identity as
required by law. However, I understand the disclosure of my name outside of the ICIG 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 ICIG 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 Inspectors
General as needed in order to carry out the responsibilities of the ICIG under PPD-19, Section C.
☐ *I understand that this form and any supporting documents transmitted to the ICIG will undergo
classification review under the National Security Act of 1947, 50 U.S.C § 3001 et seq.
☐ *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 ICIG, is a criminal
offense punishable by a fine of up to $10,000.00, imprisonment for up to five (5) years, or both.
________________________________________ ________________________________________
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EXTERNAL REVIEW PANEL (ERP) REQUEST FORM UNCLASSIFIED Within (Office of Directorate of National Intelligence, Business Transformation Office)

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Completed 18 July 2020

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