Form 1105 - NEW OARM 1105 - NEW OARM FBI Whistleblower Request for Corrective Action Form

UNITED STATES DEPARTMENT OF JUSTICE
OFFICE OF ATTORNEY RECRUITMENT AND MANAGEMENT
REQUEST FOR CORRECTIVE ACTION FORM
INSTRUCTIONS FOR COMPLETING AND FILING
YOUR REQUEST FOR CORRECTIVE ACTION
GENERAL:

This form is intended to assist you in providing the Office of Attorney Recruitment
and Management (OARM) with the information necessary to process your request
for corrective action (RCA). This form will aid OARM in determining whether
your RCA is properly before OARM, whether your request has been filed within
the applicable time limits, what claims you are raising, and what relief you seek.
You may use this form to file your RCA; however, you are not required to do so.

WHERE
TO FILE:

Your RCA must be filed with the Director of OARM, by mail to: U.S. Department
of Justice, Office of Attorney Recruitment and Management, Liberty Square
Building, 450 5th Street, N.W., Suite 10200, Washington, DC 20530-0001; by
facsimile to: (202) 514-0713; or, electronically by using the “Submit” button.

WHEN
TO FILE:

You may file an RCA with the Director of OARM only after exhausting your
Conducting Office remedies by first filing a complaint of whistleblower reprisal
with either the Department of Justice's Office of Professional Responsibility (OPR)
or the Office of Inspector General (OIG). Thereafter, your RCA must be filed
within 60 calendar days of your receipt of OPR/OIG notice of termination of its
investigation of your reprisal complaint; or, any time after 120 calendar days from
the date you first notified OPR/OIG of an alleged reprisal, if you have not been
notified that OPR/OIG will seek corrective action in your case. The date of filing
is the date on which your RCA is postmarked, or, if filed by facsimile or
electronically, the date on which it is received by OARM.

HOW
TO FILE:

You may file your RCA with the Director of OARM by mail, facsimile, or
electronically. Please note, however, that due to security delays in mail delivery to
the Department of Justice, you may wish to file your RCA by facsimile or
electronically. You may use this form, and may supplement your response to any
question on a separate sheet of paper. All of your submissions must be legible and
on 8 ½" x 11" paper.
You should not file classified and/or sensitive information with your RCA.
However, in the event such information becomes an issue in proceedings
before OARM, appropriate arrangements for the delivery, handling, and
transmission of such materials must be in compliance with FBI and other
applicable requirements regarding classified and/or sensitive materials.

PART 1 - COMPLAINANT INFORMATION
Please type or print legibly.
1. Name (last, first, middle initial)

2. Present Address:

City, State, Zip Code:
You must notify OARM in writing of any change in your mailing address while your
request for corrective action is pending.
3. Telephone Numbers (include area code) and E-Mail Address
Home: ( )

Work: ( )

FAX: ( )

Other: ( )

E-Mail Address:
You must notify OARM in writing of any change in your telephone number(s) or EMail address while your request for corrective action is pending.
4. FBI Employment or Application for Employment
Please indicate whether you are (or were) employed by the FBI, and, if so, please identify the
title and location of your position (including whether you are/were in a career or non-career
position):

If not currently or previously employed by the FBI, please list the title(s) and location(s) of the
position(s) for which you have applied:

PART 2 - EXHAUSTION OF CONDUCTING OFFICE REMEDIES

5. Have you filed a complaint of whistleblower reprisal with OPR or OIG with respect to the same
protected disclosure(s) and personnel action(s) underlying your request for corrective action?

Yes
Date reprisal complaint was filed with OPR/OIG: _____/___/____
Month Day Year

No
If "Yes," attach a copy of your reprisal complaint filed with OPR/OIG (or any other
documentation establishing that you previously filed a reprisal complaint with OPR or OIG, in
which you alleged the same protected disclosure(s) and personnel actions(s) underlying your
request for corrective action).
If "No," your request for corrective action is not properly before OARM, and you must first
file a complaint of reprisal with OPR/OIG.

6. Did you receive notice from OPR or OIG that either office terminated its investigation of your
reprisal complaint?

Yes
Date you received notification of termination: ______/_____/_____
Month Day Year

No

If "Yes," attach a partial copy of the termination letter/report from OPR or OIG (to include
only the date of the document and the statement identifying the document as a termination
letter/report). Under 28 C.F.R. § 27.3(h) and (i), the termination letter/report is not
admissible in OARM proceedings without your consent. OARM needs only the
aforementioned relevant portions to assess the timeliness of your request for corrective
action. You may redact or refrain from submitting all other portions of the letter/report.

PART 3 - REPRISAL CLAIM(S)

7. Please describe in as much detail as possible your alleged whistleblower disclosure. To the extent
you allege that you made more than one disclosure, attach separate pages (or use a copy of this
page and page 5) to answer questions 7-10 and 13 as to each additional disclosure.

8. Date on which you made your disclosure: ______/_____/_____
Month Day Year

9. To whom did you make your disclosure?
Identify that individual's title at the time you made your disclosure:

If you made your disclosure to an office, identify the office:

10. Do you believe that you made a disclosure that evidenced any of the following?
(Please check all that apply)

☐
☐
☐

Any violation of any law, rule, or regulation
Gross waste of funds
Substantial and specific danger to public health or safety

☐ Gross mismanagement
☐ Abuse of Authority

PART 3 - REPRISAL CLAIM(S) (CONTINUED)

11. Identify each personnel action taken or not taken (or threatened to be taken or not taken) against
you. Include the date of each action and the name and title of every FBI official responsible for
the action (attach separate pages as necessary).

12. Explain why you believe the alleged personnel action was taken or not taken (or threatened to be
taken or not taken) as a result of any disclosure you identified in response to question 7 (attach
separate pages as necessary).

13. Did the FBI official(s) responsible for the personnel action(s) have knowledge of your alleged
whistleblower disclosure?
Yes

No

If "Yes," identify the date on which you believe the employee(s) learned of your
disclosure: ______/_____/_____
Month Day Year
and explain why you believe the FBI official(s) knew of your disclosure (attach separate pages
as necessary).

PART 4 - DESIGNATION OF REPRESENTATIVE

14. Are you designating a representative to handle your request for corrective action?
Yes

No

If "Yes," complete the information below and sign.

Designation: I hereby designate __________________________________ to serve as my
representative during the course of my request for corrective action. I understand that my
representative is authorized to act on my behalf. In addition, I specifically authorize my
representative to settle my request for corrective action on my behalf. I understand that any
limitation on this settlement authority must be filed in writing with OARM.
By designating a representative, you agree to allow OARM to give your representative all
information concerning your request for corrective action. Any changes to this designation
must be sent in writing to OARM.
Sign here to make your designation effective:

Complainant's Signature:

Date:

Representative's Address:

City, State, Zip Code:
Representative's Telephone Numbers (include area code) and E-Mail Address
Office: (

E-Mail Address:

)

FAX: ( )

Other: ( )

PART 5 - RELIEF SOUGHT

15. What corrective action (relief or remedy) do you want OARM to order?

PART 6 - COMPLAINANT'S SIGNATURE

16. I certify that all of the statements made in this form and any supplements hereto are
true, complete, and correct to the best of my knowledge and belief.

Complainant's Signature:

Date:

PRIVACY ACT STATEMENT This information is provided pursuant to the Privacy Act of 1974, 5 U.S.C.
§ 552a(e)(3): This form requests personal information that is relevant and necessary to reach a decision in
your RCA. OARM collects this information to adjudicate requests for corrective action brought pursuant to
the FBI whistleblower regulations, 28 C.F.R. Part 27. OARM has the authority to ask for this information
pursuant to 5 U.S.C. § 301, 44 U.S.C. § 3101, and 28 C.F.R. Part 27. Because your RCA is a voluntary action,
you are not required to provide any personal information in connection with it. However, your failure to supply
OARM with all of the information essential to reach a decision in your case could result in the rejection of
your RCA. The information you provide is maintained in the JMD-023, Federal Bureau of Investigation
Whistleblower Case Files system of records, 70 Fed. Reg. 53,253 (Sept. 7, 2005), as amended 72 Fed. Reg.
3410 (Jan. 25, 2007), 72 Fed. Reg. 15,906 (Apr. 3, 2007), and 72 Fed. Reg. 30,631 (June 1, 2007). If you
supply OARM with your information, your information may be disclosed by the Department of Justice in
accordance with the provisions of the Privacy Act, including to contractors, grantees, experts, consultants, and
others performing or working on a contract, service, grant, cooperative agreement, or other assignment for the
Federal Government when necessary to accomplish an agency function related to this system of records, to
the National Archives and Records Administration in connection with records retention or disposition issues,
or for other routine uses indicated in the JMD-023, Federal Bureau of Investigation Whistleblower Case Files
system of records notice. To view the routine uses applicable to this system of records, please consult the
system of records notice, as amended, at the following links:
70 Fed. Reg. 53,253 at https://www.gpo.gov/fdsys/pkg/FR-2005-09-07/pdf/05-17700.pdf;
72 Fed. Reg. 3410 at https://www.gpo.gov/fdsys/pkg/FR-2007-01-25/pdf/E7-1176.pdf;
72 Fed. Reg. 15,906 at https://www.gpo.gov/fdsys/pkg/FR-2007-04-03/pdf/E7-6108.pdf;
72 Fed. Reg. 30,631 at https://www.gpo.gov/fdsys/pkg/FR-2007-06-01/pdf/E7-10523.pdf.

Submit