Form NHTSA Form 1684 NHTSA Form 1684 FORM WB-INFO WHISTLEBLOWER SUBMISSION

Appendix A to Part 513- Form WB-INFO

OMB Number: 2127-0767

Exp. [DATE]

NHTSA Form 1684

UNITED STATES DEPARTMENT OF TRANSPORTATION

NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA)

FORM WB-INFO

WHISTLEBLOWER SUBMISSION

See Privacy Act Statement, Submission Procedures, and Completion Instructions below.

A. INFORMATION ABOUT YOURSELF
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. Telephone	11. Alt. Phone		12. Email Address		13. Preferred Method of Communication
14. Occupation
15. Current Employer Name
16. Current Employer Address
17. Your relationship to the company about whom the concern is raised:
B. INFORMATION ABOUT THE MOTOR VEHICLE MANUFACTURER, PART SUPPLIER, OR DEALERSHIP ABOUT WHICH THE CONCERN IS RAISED
1. Company Name
2. Street Address
3. City		4. State/Province		5. ZIP/Postal Code	6. Country
7. Do you or did you work for the motor vehicle manufacturer, part supplier or dealership about which the concern is raised? [] Yes [] No If yes, please provide dates. If no, please identify what motor vehicle manufacturer, part supplier or dealership you work or worked for:
8. Does this motor vehicle manufacturer, part supplier or dealership have an internal reporting mechanism? [] Yes [] No [] I Don’t Know
9. If the answer to number 8 above is yes, did you report this issue through the internal reporting mechanism? [] Yes. Date Reported: ___________________ [] No. Reason for not reporting____________________________________________________________________________ [] No. Reason for not reporting____________________________________________________________________________

C. LEGAL REPRESENTATIVE INFORMATION (If Applicable – See Instructions)
1. Legal representative’s Name
2. Firm Name
3. Street Address
4. City	5. State/Province		6. ZIP/Postal Code	7. Country
8. Telephone		9. Email address

D. TELL US ABOUT THE ISSUE INVOLVING THE MOTOR VEHICLE MANUFACTURER, PART SUPPLIER, OR DEALERSHIP
1. Date(s) of alleged conduct:	2. Is the conduct ongoing? [] Yes [] No [] I Don’t Know
3a. Have you or your legal representative had any prior communication with the NHTSA concerning this matter? [] Yes [] No 3b. If yes, provide the name of the NHTSA staff member(s) with whom you or your legal representative communicated and date of such communication:
4a. Is your allegation related to a potential safety-related defect or a noncompliance with an applicable Federal Motor Vehicle Safety Standard? [] Yes [] No 4b. If yes, please provide a detailed description of allegation and a detailed description of how the allegation affects vehicle/system/component performance and/or compliance. Please include the make, model, model year, part number, component number, etc. if known
5a. Is your allegation related to any violation or alleged violation of any notification or reporting requirement of the Safety Act? [] Yes [] No 5b. Provide a description of the notification or reporting issue. State in detail all facts pertinent to the alleged violation.
6. Describe all supporting materials in your possession and the availability and location of any additional supporting materials not in your possession. If necessary, please use additional sheets.

E. ADDITIONAL INFORMATION (USE ADDITIONAL SHEETS IF NECESSARY)

1. Describe how you learned about or obtained the information that supports your allegations. In addition, if any information was obtained from a public source, identify the source with as much particularity as possible.

2. Identify with particularity any documents or other information in your submission that you believe could reasonably be expected to reveal your identity and explain the basis for your belief that your identity could be reasonably expected to be revealed if the documents or information were disclosed to a third party.

3a. Have you or your legal representative taken any other action regarding the issue or your allegations? [] Yes [] No

3b. If “Yes,” please provide details. Use additional sheets, if necessary.

4. Did you acquire the information through a means or manner that has been determined by a United States federal court or a state court to violate applicable federal or state criminal law? [] Yes [] No

If the answer to this question is yes, please contact NHTSA’s Office of the Chief Counsel before you submit this form.

5. Did you acquire the original information that you are submitting to NHTSA solely through a communication that was subject to a privilege, such as the attorney-client privilege or attorney work product doctrine? [] Yes [] No

If the answer to this question is yes, please contact NHTSA’s Office of the Chief Counsel before you submit this form.

6. Provide any additional information that you think may be relevant. Attach additional sheets if necessary.

F. PROSPECTIVE WHISTLEBLOWER’S DECLARATION
I declare under penalty of perjury under the laws of the United States that the information contained herein is true and correct to the best of my knowledge, information and belief. I fully understand that I may be subject to prosecution and ineligible for a whistleblower award if, in my submission of information, my other dealings with the National Highway Traffic Safety Administration, or my dealings with another authority in connection with a related action, I knowingly and willfully make any false, fictitious or fraudulent statements or representations, or use any false writing or document knowing that the writing or document contains any false, fictitious or fraudulent statement or entry.
Print Name
Signature	Date

G. CERTIFICATION OF LEGAL REPRESENTATIVE OF ANONYMOUS WHISTLEBLOWER (IF APPLICABLE)
I certify that I have reviewed this form for accuracy and that the information contained herein is true and correct to the best of my knowledge, information and belief. I further certify that I have verified the identity of the person on whose behalf this form is being submitted by viewing the person’s valid, unexpired government issued identification (e.g., driver’s license, passport) and will retain an original, signed copy of this form, with Section F signed by the person, in my records. I further certify that I have obtained the person’s non-waivable consent to provide the National Highway Traffic Safety Administration with the original signed WB-INFO form in the event that the National Highway Traffic Safety Administration requests it.
Print Name of Legal representative and Law Firm, if Applicable
Signature	Date

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, or a legal representative acting on such person’s behalf, who wishes to provide NHTSA with information relating to any potential motor vehicle defect, potential noncompliance, or any violation or alleged violation of any notification or reporting requirements of 49 U.S.C. Chapter 301 or regulation thereunder, which is likely to cause unreasonable risk of death or serious physical injury. The information provided will allow the Agency to evaluate the claim and elicit information relevant to whistleblower eligibility requirements. This information may be disclosed to the U.S. Department of Justice or an appropriate department or agency of the Federal Government, acting within the scope of its jurisdiction, consistent with the confidentiality requirements set forth in 49 U.S.C. § 30172(f). NHTSA may also disclose information that could reasonably be expected to reveal the identity of a whistleblower in certain limited situations, including when the whistleblower provides prior written consent. Id.

Furnishing the information contained in this form is voluntary but a decision not to do so will result in you not being eligible for award consideration.

Questions concerning this form may be directed to the National Highway Traffic Safety Administration, Office of the Chief Counsel by email to [email protected].

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 may 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 the 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. Chapter 301).

General Information

• To be eligible for an award under NHTSA’s whistleblower program, you must first provide us with your information through one of two ways. After completing this WB-INFO form, send it to NHTSA electronically to [email protected], or submit it by any such method that the Agency may expressly designate on its website (https://www.nhtsa.gov/laws-regulations/whistleblower-program).

• Submitting your information is the first step. If the information you submit leads to the successful resolution of a covered action that in the aggregate results in collected monetary sanctions exceeding $1,000,000, you will have an opportunity at a later date to submit a claim for an award. That is a separate process and is described in our whistleblower rules at 49 C.F.R. Part 513.

• You have the right to submit information anonymously. If you are submitting information anonymously, you must be represented by a legal representative in this matter and Sections C and G of this form must be completed. Otherwise, you may, but are not required to, have a legal representative. If you are submitting information anonymously, please skip Part I of these instructions and proceed directly to Part II. Otherwise, please begin by following the instructions in Part I.

Part I: Instructions for filers who are disclosing their identity to NHTSA

• You are required to complete Sections A, B, D, E, and F of this form. If you are represented by a legal representative in this matter, you must also complete section C. Specific instructions for answering these questions can be found in Part IV below.

• If you are represented, your legal representative does not need to complete Section G.

• You will need to submit the WB-INFO form in accordance with the Submission Procedures in 49 C.F.R. Part 513.

Part II: Instructions for anonymous filers

• If you are submitting information anonymously, you must be represented by a legal representative on this matter.

• You are required to complete Sections A, B, C, D, E, and F of this form and give the signed original to your legal representative. Specific instructions for answering these questions can be found in Part IV below.

• Your legal representative must retain your signed original WB-INFO form.

Part III. Instructions for legal representatives representing anonymous filers

• Obtain a completed and signed original WB-INFO form, filled out in accordance with the Part II above. You must retain this signed original in your records.

• You must prepare a WB-INFO form, completing Sections B, C, D, and E with your client’s information. You must also sign the declaration in Section G.

• You will need to submit the WB-INFO form you completed in accordance with submission procedures in 49 C.F.R. Part 513.

Part IV. Instructions for Completing Form WB-INFO

Section A: Information About Yourself

Questions 1-16: Please provide the following information about yourself:

• Last name, first mame, and middle initial;

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

• Your telephone number, and if available, an alternate number where you can be reached;

• Your email address (to facilitate communications, you are strongly encouraged to provide your email address);

• Your preferred method of communication;

• Your occupation;

• Your current employer;

• Your current employer’s address; and

• Your relationship to the company about whom the concern is raised.

Section B: Information About the Motor Vehicle Manufacturer, Part Supplier, or Dealership About Which the Concern is Raised

Questions 1-7: Please provide the following information about the motor vehicle manufacturer, part supplier, or dealership about which the concern is raised:

• Company name of the motor vehicle manufacturer, part supplier or dealership;

• Complete address of the motor vehicle manufacturer, part supplier, or dealership, including city, state/province, zip/postal code, and country; and

• Complete whether you work or worked for the motor vehicle manufacturer, part supplier, or dealership about whom the concern is raised. If yes, please provide dates that you work or worked for the company. If no, provide the name of the motor vehicle manufacturer, part supplier, or dealership you work or worked for.

Question 8: Please check the correct box stating whether the motor vehicle manufacturer, part supplier, or dealership about which the concern was raised has or had an internal reporting mechanism. The choices are yes, no, and I don’t know.

Question 9: If you checked the “yes” box in response to the question of whether the motor vehicle manufacturer, part supplier or dealership had an internal reporting mechanism, please provide the following information:

• If you reported the issue through your company’s internal reporting mechanism, check the box “yes” and provide the date that you reported to the internal reporting mechanism.

• If you did not report the issue through your company’s internal reporting mechanism, check the box “no” and provide your reason for not reporting to the internal reporting mechanism.

Section C: Legal representative Information. Complete this section only if you are represented by a legal representative in this matter. If you are submitting your information anonymously and you want to be considered for an award under NHTSA’s whistleblower program, you must be represented by a legal representative, and this section must be completed.

Questions 1-9: Provide the following information about the legal representative representing you in this matter:

• Legal representative’s name;

• The legal representative’s firm’s name;

• The firm’s complete address, including city, state, and zip code;

• Your legal representative’s telephone number; and

• Your legal representative’s email address.

Section D: Tell Us About the Issue Involving the Motor Vehicle Manufacturer, Part Supplier, or Dealership:

Question 1: Please provide the date that the alleged conduct began.

Question 2: Check the option that best describes whether the alleged conduct is ongoing.

Question 3a: Indicate whether you or your legal representative have had any prior communication with the National Highway Traffic Safety Administration (“NHTSA”) concerning this matter.

Question 3b: If you answered “yes” to Question 3a, provide the name of the NHTSA staff member(s) with whom you or your counsel communicated and date of such communication.

Question 4a: Check the option that best describes whether your allegation is related to a potential safety-related defect or noncompliance with an applicable Federal Motor Vehicle Safety Standard (FMVSS).

Question 4b: If you answered “yes” to Question 4a, provide a detailed description of the allegation and a detailed description of how the allegation affects vehicle/system/component performance and/or compliance. Please include the make, model, model year, part number, component number, etc. if known.

Question 5a: Check the option that best describes whether your allegation is related to any violation or alleged violation of any notification or reporting requirement of the Safety Act.

Question 5b: If you answered “yes” to Question 5a, provide a description of the notification or reporting issue. State in detail all facts pertinent to the alleged violation.

Question 6: Describe all supporting materials in your possession and the availability and location of additional supporting materials not in your possession. Attach additional sheets if necessary.

Section E: Additional Information

Question 1: Describe how you learned about or obtained the information that supports your allegations. In addition, if any information was obtained from a public source, identify the source with as much particularity as possible. Attach additional sheets if necessary.

Question 2: Identify with particularity any documents or information in your submission that you believe could reasonably be expected to reveal your identity, and explain the basis for your belief that your identity could be reasonably expected to be revealed if the documents or information are disclosed to a third party.

Question 3a: Check the option that best describes whether you or your legal representative have taken any other action regarding the issue or your allegations.

Question 3b: If your answer to Question 3a was “Yes,” provide details. Use additional sheets if necessary.

Question 4: Check the option that best describes whether you acquired information through a means or manner that has been determined by a United States federal court or a state court to violate applicable federal or state criminal law. The question also contains a statement that if the answer to this question is yes, to please contact NHTSA’s Office of the Chief Counsel before you submit this form.

Question 5: Check the option that best describes whether you acquired the original information that you are submitting to NHTSA solely through a communication that was subject to a privilege, such as the attorney-client privilege or attorney work product doctrine. The question also contains a statement that if the answer to this question is yes, to please contact NHTSA’s Office of the Chief Counsel before you submit this form.

Question 6: Provide any additional information that you think may be relevant. Attach additional sheets if necessary.

Section F: Prospective Whistleblower’s Declaration

This is to be completed and signed by the person submitting the information.

Section G: Legal representative Certification

This is to be completed and signed by a legal representative for an anonymous person submitting information. If you have a legal representative and are not submitting this form anonymously, this section does not need to be completed.