Whistleblower Program Forms

Forms and Documents

Document Name	Status
Form NHTSA Form 1686 WB-AWARD-Individual with Legal Representative Form and Instruction	New
Form NHTSA Form 1685 WB-RELEASE-Individual with Legal Representative Form and Instruction	New
Form NHTSA Form 1685 WB-RELEASE-Individual Form and Instruction	New
Form NHTSA Form 1684 WB-INFO- Individual with Legal Representative Form and Instruction	New
Form NHTSA Form 1684 WB-INFO-Individual Form and Instruction	New
2023-09-07 PRA Supporting Statement.Clean.docx Supporting Statement A	2023-10-12

IC Document Collections

IC ID	Document Title	Status
262370	WB-AWARD-Individual with Legal Representative Form and Instruction	New
262369	WB-RELEASE-Individual with Legal Representative Form and Instruction	New
262368	WB-RELEASE-Individual Form and Instruction	New
262367	WB-INFO- Individual with Legal Representative Form and Instruction	New
262366	WB-INFO-Individual Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202309-2127-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOT/NHTSA	Agency Tracking No:
Title: Whistleblower Program Forms
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/16/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	97	0
Time Burden (Hours)	781	0
Cost Burden (Dollars)	279,965	0

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Abstract: This proposed information collection request (ICR) relates to three new forms necessary for the efficient operation of the National Highway Traffic Safety Administration’s (NHTSA) whistleblower program, as established by 49 U.S.C. 30172 (the Whistleblower Act). The Whistleblower Act authorizes the Secretary of Transportation (the Secretary) to pay an award to eligible whistleblowers who voluntarily provide original information, if the information provided leads to the successful resolution of a covered action. The three forms are the WB-INFO form, the WB-AWARD form, and the WB-RELEASE form. All of the information collections are collected on an as-needed basis. One of the information collections is completely voluntary and the other two are voluntary, but required to receive a benefit. Under the proposed regulations, a potential whistleblower is required to submit a WB-INFO form and to submit a WB-AWARD form in order to qualify for a whistleblower award. A potential whistleblower may choose to voluntarily submit the WB-RELEASE form. The proposed WB-INFO form will be used to permit NHTSA and its staff to collect information from potential whistleblowers about themselves, their legal representatives, and their allegations relating to any potential violation of the Safety Act or regulation thereunder. If a potential whistleblower proceeds anonymously, the individual must have a legal representative. That legal representative will retain their client’s signed WB-INFO form. The WB-AWARD form would permit NHTSA to collect information relating to a claimant’s eligibility for an award. This would allow NHTSA’s Administrator to determine claims for whistleblower awards. The WB-RELEASE form would provide a means for the potential whistleblower to provide consent for NHTSA to disclose information which could reasonably be expected to reveal the identity of the potential whistleblower. Being able to disclose this information may allow NHTSA to open a public investigation or proceed more efficiently with an investigation into the potential whistleblower’s allegations. The likely respondents to proposed forms, the WB-INFO, the WB-AWARD, and the WB-RELEASE, are those employees or contractors of motor vehicle manufacturers, part suppliers, and dealerships who wish to provide NHTSA staff with information relating to any potential motor vehicle defect, potential noncompliance, or any violation or alleged violation of any notification or reporting requirement of the Safety Act or regulation thereunder. The anticipated recipients of the proposed WB-INFO, WB-AWARD and WB-RELEASE forms are those individuals at NHTSA who have a need to know the information. This may include attorneys in NHTSA’s Office of the Chief Counsel and staff in NHTSA’s Office of Enforcement.

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Authorizing Statute(s): US Code: 49 USC 30172 Name of Law: the Whistleblower Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2127-AL85	Proposed rulemaking	88 FR 23276	04/14/2023

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
WB-AWARD-Individual with Legal Representative	NHTSA Form 1686	FORM WB-AWARD WHISTLEBLOWER AWARD APPLICATION
WB-INFO- Individual with Legal Representative	NHTSA Form 1684	FORM WB-INFO WHISTLEBLOWER SUBMISSION
WB-INFO-Individual	NHTSA Form 1684	FORM WB-INFO WHISTLEBLOWER SUBMISSION
WB-RELEASE-Individual	NHTSA Form 1685	FORM WB-RELEASE WHISTLEBLOWER RELEASE FORM
WB-RELEASE-Individual with Legal Representative	NHTSA Form 1685	FORM WB-RELEASE WHISTLEBLOWER RELEASE FORM

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	97	0	0	97	0	0
Annual Time Burden (Hours)	781	0	0	781	0	0
Annual Cost Burden (Dollars)	279,965	0	0	279,965	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is the implementation of a new program. NHTSA estimates the burden hours will be 750 hours for the WB-INFO form, 11.25 hours for the WB-RELEASE Form and 20 hours for the WB-AWARD form. The total estimated annual burden hours for this information collection are 781 hours (rounded).

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Annual Cost to Federal Government: $11,382

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/16/2023

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