OPTIONAL EMPLOYEE DISCLOSURE FORM
DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION
Purpose: This form is to provide employees with an optional method of submitting a disclosure to the Office of Accountability and Whistleblower
Instructions: Please read the entire instruction.
What is a disclosure? Information provided by an employee that the employee reasonably believes shows:
- a potential violation of any law, rule or regulation; or
- gross mismanagement; or
- gross waste of funds; or
- abuse of authority, or
- substantial and specific danger to public health or safety.
Retaliation for making protected disclosures is against the law. If you believe you are being, or have been, retaliated against for making a protected
disclosure, you may submit a disclosure regarding the retaliation.
What is gross mismanagement? Management action or inaction which creates a substantial risk of significant adverse impact upon the agency's ability to
accomplish its mission.
What is a gross waste of funds? More than debatable expenditure that is significantly out of proportion to the benefit reasonably expected to accrue to the
What is an abuse of authority? The arbitrary or capricious exercise of power by a Federal official or employee that adversely affects the rights of any person
or that results in personal gain or advantage to him-or-herself or to the preferred other person.
What is a substantial and specific danger? To qualify as a disclosure under this provision, the danger must encompass both being “substantial” and
“specific”. Such disclosures cannot be vague or speculative. Substantial danger must be considered in terms of the potential consequences. Specific danger
must be viewed in terms of the likelihood of harm and when such harm may occur. A danger whose likelihood of harm would only exist under speculative
or improbable conditions would not qualify as such a disclosure. A harm more likely to occur in the immediate or near future is more likely to qualify as a
substantial and specific danger than a harm likely to manifest in the distant future.
Other avenues for disclosures: Use or submission of this form does not prevent or limit an employee from filing through one of the other avenues available
under law including, but not limited to submitting directly to the VA's Office of inspector General, the Office of Special Counsel, or to Congress.
See Available Avenues of Redress for VA Employees at http://vaww.va.gov/ohrm/employeerelations/grievance_appeals/avenues_redress.pdf.
Additional information: A more complete explanation of employee rights to file a disclosure and the protections available in doing so can be found on the
VA's Internet site at http://vaww.va.gov/employee/ (scroll to bottom of page).
Filing a disclosure: You may use this form to file a disclosure under these procedures. You may use one of the other avenues described above in addition to,
or in place of, using these procedures.
You are not and cannot be required to submit a disclosure to or through supervisory channels.
To use this form, complete Parts 1 through 4 of this form in as much detail as possible and submit the completed form to (see the Guide to Disclosures for
more detailed information):
- your supervisor; or
- the next level of supervision that has not already received the disclosure; or
- the Office of Accountability and Whistleblower Protection.
Including additional information: You may attach any supporting materials or documentation you determine necessary.
What happens next: If you submit the completed form to the Office of Accountability and Whistleblower Protection and you include an e-mail address, you
will receive an acknowledgement message that includes the case number assigned to your submission. Your submission will be reviewed and you will be
informed of the progress of the review and additional actions.
Filing directly with the Office of Accountability and Whistleblower Protection (OAWP): While employees are welcome to file directly with the OAWP, or
any other avenue, employees are encouraged to consider whether their disclosure would be more rapidly addressed at a local level. To file a disclosure
directly with the OAWP, submit your completed form to VAAccountabilityTeam@va.gov. This address can accept encrypted messages. Alternatively, you
may also send your completed form via fax to 202-495-5601.
Anonymous disclosures: The OAWP may not disclose the identity of an employee who submits a whistleblower disclosure to the OAWP without your
consent. If you do not wish to file a disclosure form, you may also call the toll- free hotline at 855-4AWONOW (855-429-6669). If you call the toll-free
hotline, you will be asked to record the details of your disclosure. Please provide your contact information and as much detail as possible such as, your
facility or office, specific dates and times, the particular information about your disclosure, and who is involved. Providing detailed information will assist
getting your disclosure addressed effectively and as quickly as possible.
VA FORM 10177, JUN 2020
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