Online Intake Application

DISCLAIMER:

Submitting an application to Government Accountability Project or communicating with us about
your application does not mean that Government Accountability Project is representing you.
Indeed, Government Accountability Project lawyers are not representing you unless and until
you receive written notification and have signed a retainer agreement. Until such point, your
application is under consideration, and if we request more information or documents from you,
this is only a part of the application process.

Please be advised that Government Accountability Project cannot guarantee prompt review or a
decision regarding your intake application. You should educate yourself about the deadlines
and/or statute of limitations associated with your case. Government Accountability Project is not
responsible for alerting you to such limitation periods during the application process.

Do not include any classified information in your application. If your case involves
classified information, please indicate that it does without revealing the information.

In addition, we strongly suggest that you complete this application from a personal, non-work
computer.

I have read, understood, acknowledge and agree to the conditions and terms mentioned in the "Disclaimer" above.

A completed form will allow us to properly review your potential case and make a
determination as to whether or not we might be able to help.

Please answer the following
questions to allow us to adequately assess your case. Forms not completed in full may
not be reviewed.

Are you currently represented by an attorney in connection with any aspect of this matter?

Yes

First Name

Last Name

Street Address

Street Address Line 2

City

Postal Code

State/Province

Phone Number

Where did you hear about Government Accountability Project?

Internet Research

News Report

Government Official

Nonprofit Organization

Friend

Co-Worker

Other…

What type of assistance are you seeking from Government Accountability Project?

Legal Representation

Other Advocacy Support or Advice

Not Sure

Please describe how you would like Government Accountability Project to help you:

Are You:

An employee (or former employee) who has already reported wrongdoing that you learned about in your workplace, either to someone within your organization or to an external Agency?

An employee (or former employee) who has learned about wrongdoing in your workplace that you are interested in reporting, but who has not yet done so?

A journalist working with a whistleblower or employee source?

A public interest organization staff member working with a whistleblower or employee source?

An attorney seeking expertise?

Other…

Employment status:

Are you or were you an employee of a federal contractor or grantee?

Yes

Employment Details

Please provide the information requested below, to the best of your ability, for your
most recent position and any other position that you have held that is relevant to the misconduct
you observed.

All fields in this section are required for each entry added.

Employment Details
	Title (for instance, Investigator) Employment Grade (for instance, GS-9) Start Date of employment End Date of empoyment Department Name Agency Name Agency subcomponent Street Address City State Country (If outside United States) Postal Code Are you covered by a collective bargaining agreement? Competitive Service Which of the following apply to your employment status? Excepted Service Which of the following apply to your employment status? Senior Executive Service (SES) or Executive Level Which of the following apply to your employment status? Other Which of the following apply to your employment status?	Item weight

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Non-Federal Employment Details

All fields in this section are required for each entry added.

Non-Federal Employment Details
	Name of Organization for which you work Your Title Start Date of Employment End Date of Employment (If Applicable) Brief Description of your Responsibilities	Item weight

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Do you or did you work for

Disclosure Section

Disclosure Details

Re-order	Please identify the type of wrongdoing that you have disclosed.	What did you Disclose?	To whom, within your organization, did you make your disclosure/	How did you learn of the information you disclosed?	Did individuals in your organization, other than those to whom you disclosed the information, learn about your disclosure(s)?	If Yes, Who learned of your disclosure(s) and How did they learn about your disclosure(s)?	What action (if any) did the organization take in response to your disclosure?	Weight	Operations
	Please identify the type of wrongdoing that you have disclosed.	What did you Disclose?	To whom, within your organization, did you make your disclosure/ You may enter multiple people within your organization, disclosures made outside of your organization are addressed further below.	How did you learn of the information you disclosed?	Did individuals in your organization, other than those to whom you disclosed the information, learn about your disclosure(s)? Yes No	If Yes, Who learned of your disclosure(s) and How did they learn about your disclosure(s)?	What action (if any) did the organization take in response to your disclosure? (for example, did the organization investigate or otherwise look into what you disclosed or was disciplinary action taken against responsible parties?)	Item weight

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If you check "violation of law, rule, or regulation" specify, if you can, the particular law, rule or regulation violated (by name, subject, and/or legal citation). If you have made multiple disclosures, please provide the information below for each disclosure by choosing “add another disclosure” at the bottom of the section.

Do you believe you have suffered retaliation because of your disclosure(s)?

Yes

Describe:

When was the action taken? By whom?

Please provide Date, Name and Title along with additional comments.

If applicable, what was the organization’s stated reason for taking the action?

Do you have any evidence that you were treated more harshly than other employees for the same alleged offense (“disparate treatment” )?

What facts suggest that the action(s) is/are retaliatory?

For example, were comments
made that suggest that individuals at the organization were angry because of your
disclosure or did you notice changes in your relationships following your disclosure?

Why do you believe individuals from your organization would retaliate against you?

For example, did they suffer adverse consequences or embarrassment because of your
disclosure?

Please provide the name, title, and position in your chain of command of the individuals involved in taking any personnel action(s) that you believe was retaliatory

Re-order	First Name	Last Name	Title	Chain of Command	Weight	Operations
	First Name	Last Name	Title e.g. Deputy Director	Chain of Command e.g. 1st Level Supervisor	Item weight

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HAVE YOU REPORTED THIS MATTER ELSEWHERE?

Yes

Have you sought assistance outside of your workplace prior to contacting Government
Accountability Project and/or shared the information you have disclosed with anyone not
noted in question [FILL IN AFTER NUMBERING COMPLETED] above ? (e.g., other
attorneys, a union representative, another non-profit organization, an elected official’s
office, an oversight agency, the media etc.)

Please indicate with whom you have shared this information, when you shared it, and what response you received, if any.

Reported matter to member(s) of Congress

Reported matter to an agency Inspector General

Submitted a Tips, Complaints and Referrals form to the Securities and Exchange Commission (SEC)

Reported matter to state attorney general

Press/Media (newspaper, television, other)

Other…

Congress Report Details

Re-order	Name of Senator or Representative and, if applicable, staff person you communicated with	Date Reported	Weight	Operations
	Name of Senator or Representative and, if applicable, staff person you communicated with	Date Reported	Item weight

IG Report Details

Re-order	To which agency IG did you report?	Date Reported	Status/Response	Weight	Operations
	To which agency IG did you report?	Date Reported	Status/Response	Item weight

SEC Report Details

Re-order	Date Reported	Status/Response	Weight	Operations
	Date Reported	Status/Response	Item weight

AG Report Details

Re-order	Date Reported	Status/Response	Which State	Weight	Operations
	Date Reported	Status/Response	Which State	Item weight

Media Report Details

Re-order	Please specify the organization, the individual(s) with whom you have communicated, the date you contacted them, and what response you received, if any.	Weight	Operations
	Please specify the organization, the individual(s) with whom you have communicated, the date you contacted them, and what response you received, if any.	Item weight

Other Report Details

Re-order	Please indicate to whom you reported and what response you received, if any.	Date Reported	Weight	Operations
	Please indicate to whom you reported and what response you received, if any.	Date Reported	Item weight

Have you filed any claims, taken any action to appeal or grieve this matter, or been involved in any legal proceedings in connection with the underlying misconduct or related retaliation?

Yes

Action(s) Taken

Re-order	Type of Action	Date Filed	Status	Outcome (If concluded)	Claims asserted (if applicable)	Court name (if applicable)	Weight	Operations
	Type of Action Type of Action Enter other…	Date Filed	Status	Outcome (If concluded)	Claims asserted (if applicable)	Court name (if applicable)	Item weight

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Add as many rows as applicable.

Did you have legal representation when participating in any of the matters selected above?

Yes

Who represented you? Why do they no longer represent you?

Interested in Disclosure Section

Please identify the type of wrongdoing you are interested in disclosing

Violation of law, rule, or regulation

Gross mismanagement

Gross waste of funds

Abuse of authority

Substantial and specific danger to public health

Substantial and specific danger to public safety

Check ALL
that apply. If you check violation of law, rule, or regulation, specify, if
you can, the particular law, rule or regulation violated (by name, subject, and/or legal
citation.

What misconduct occurred?

Who took the action(s) involved in this misconduct?

Re-order	First Name	Last Name	Title	Weight	Operations
	First Name	Last Name	Title	Item weight

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What action(s) did they take?

When did the action(s) occur?

How did you discover the action(s)

Why do you believe the action(s) is/are [depending on selection(s) above: a violation of law, rule, or regulation; gross mismanagement; a gross waste of funds; an abuse of authority; a substantial and specific danger to public health; a substantial and specific danger to public safety; censorship related to scientific research]

Have you sought assistance outside of your workplace prior to contacting Government Accountability Project?

Yes

Please list where you have already sought assistance and what support they offered you, if any.

What are your goals in this matter? (Check all that apply.)

Expose and address the wrongdoing

Address retaliation I have experienced because of whistleblowing

Prevent retaliation/further retaliation

Receive compensation

Become engaged in the larger community of whistleblowers

Other…

If you are seeking legal representation, can you afford Government Accountability Project’s standard non-profit attorney fee for services of approximately $85-$175 per hour?

Yes

Please note your ability to pay is not the primary factor Government Accountability Project considers in our decision to represent you. However, we do expect people with means and an income to contribute toward their representation as well as expenses; this enables us to help as many people as possible. Our public interest rates are a fraction of what private attorneys charge. In addition, we do not charge initial consultation fees for an inquiry regarding representation.

In addition, are you able to pay the expenses associated with litigation, such as depositions, print materials or travel expenses, if necessary?

Yes

Any additional comments

Thank you for your submission. Our legal team carefully reviews all submissions. It may take up
to one month for us to review your application. If you do not hear from us within a month, please
call us at 202.457.0034. As a reminder, you are responsible for understanding the deadlines
associated with your case, and Government Accountability Project is not responsible for alerting
you that a deadline is approaching during the application process.
For further information about whistleblowing, please visit our Resources page.

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