Form NHTSA Form 1685 NHTSA Form 1685 FORM WB-RELEASE WHISTLEBLOWER RELEASE FORM

Appendix B to Part 513- FORM WB-RELEASE

OMB Number: 2127-0767

Exp. [DATE]

NHTSA Form 1685

UNITED STATES DEPARTMENT OF TRANSPORTATION

NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA)

FORM WB-RELEASE

WHISTLEBLOWER RELEASE FORM

See Notice of Whistleblower Rights and Protections, Privacy Act Statement, Submission Procedures, and Completion Instructions below.

A. Information
1. Last Name	2. First Name		3. M.I.
4. Street Address			5. Apartment/Unit #
6. City	7. State/Province	8. ZIP/Postal Code	9. Country
10. Name of the motor vehicle manufacturer, part supplier, and/or dealership to which this issue relates:

B. Release

I understand that in the course of an inquiry or analysis surrounding my allegations, it may become necessary for NHTSA to reveal information that reasonably could be expected to reveal my identity to persons or their counsel or agents at the organization or institution against which such allegations are made or other entities.

CONSENT - I have read and understand the above information and authorize NHTSA to reveal any information that could reasonably be expected to reveal my identity to persons at the organization or institution against which my allegations are made, or their agents or counsel, to governmental entities outside the United States and to other persons or entities that NHTSA determines should have access to this information to assist in NHTSA’s analysis, inquiry or investigation. I further understand that I am not required to consent to this release, and do so voluntarily.

C. Prospective Whistleblower’s Signature
Signature	Date

Notice of Whistleblower Rights and Protections

This brief description will provide you with an overview of the whistleblower rights and protections.

Whistleblowers, as that term is defined in 49 U.S.C. § 30172(a)(6), have a right to keep their identity confidential in most situations. 49 U.S.C. § 30172(f). Generally speaking, any information which reasonably could be expected to reveal the identity of a whistleblower can be disclosed only under limited circumstances. One circumstance where NHTSA could reveal such information is if the whistleblower gives prior written consent. 49 U.S.C. § 30172(f)(1)(B).

The Freedom of Information Act (FOIA), 5 U.S.C. § 552, gives the public access to records of the Federal Government. Individuals can obtain information from many categories of records of the Government--not just materials that apply to them personally. NHTSA must honor requests under the FOIA, with some exceptions. Information that could reasonably be expected to reveal the identity of a whistleblower is exempted from FOIA disclosure by statute. See 49 U.S.C. § 30172(f)(3); 5 U.S.C. § 552(b)(3)(B).

NHTSA may disclose information that could reasonably be expected to reveal the identity of a whistleblower if it follows the provisions of 5 U.S.C. § 552a (the Privacy Act of 1974). 49 U.S.C. § 30172(f)(1). The Privacy Act prohibits the disclosure of information from a system of records (where information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual) absent the written consent of the subject individual, unless the disclosure is pursuant to one of twelve statutory conditions.

Furthermore, under 49 U.S.C. § 30171, employees providing certain motor vehicle safety information have protections from discrimination. Under 49 U.S.C. § 30171(a)(1), a motor vehicle manufacturer, parts supplier or dealership may not discharge an employee or otherwise discriminate against the employee because the employee provided, caused to be provided, or is about to provide (with knowledge of the employer) or cause to be provided to the employer or the Secretary of Transportation information relating to any motor vehicle defect, noncompliance, or any violation or alleged violation of any notification or reporting requirement of the Safety Act (49 U.S.C. 30101 et. seq.).

Privacy Act Statement

The Privacy Act of 1974 requires that the National Highway Traffic Safety Administration (“NHTSA”) inform individuals of the following when asking for information. This form may be used by an employee or contractor of a motor vehicle manufacturer, part supplier, or dealership who wishes to provide prior written consent for the Agency to disclose information which could reasonably be expected to reveal their identity. Furnishing this form is voluntary.

Questions concerning this form may be directed to the National Highway Traffic Safety Administration, Office of the Chief Counsel by email at [email protected], or a NHTSA attorney with whom you have previously been in contact.

General Information and Submission Procedures

• This form should be used by persons that want to provide prior written consent to the Agency to disclose information which could reasonably be expected to reveal their identity.

• You must sign the WB-RELEASE form as the prospective whistleblower.

• You must submit your form to NHTSA in one of following ways: by emailing it to [email protected] or by any such method that the Agency may expressly designate on its website (https://www.nhtsa.gov/laws-regulations/whistleblower-program).

Instructions for Completing Form WB-RELEASE

Section A: Information

Questions 1-9: Please provide the following information about yourself:

• last name, first name, and middle initial; and

• Complete address, including city, state/province, zip/postal code, and country.

Question 10: Please provide the name of motor vehicle manufacturer, part supplier and/or dealership to which the issue relates.

Section B: Release

Check the box before the word “CONSENT” to indicate your consent to allow the Agency to reveal any information that could reasonably be expected to reveal your identity to persons at the organization or institution against which your allegations are made, or their agents or counsel, to governmental entities outside the United States and to other persons or entities that NHTSA determines should have access to this information to assist in NHTSA’s analysis, inquiry or investigation.

This section also informs you that you are not required to consent to this release and that you do so voluntarily.

Section C: Prospective Whistleblower’s Signature

This section must be signed and dated by the prospective whistleblower.