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Employee Concerns Reporting Form

Employee Concerns Program Policy Statement

DOE/NNSA recognizes that free and open expression of employee concerns is fundamental and essential to the safe and efficient operations of the Department's mission. Employees of the DOE/NNSA and any contractor or subcontractor fulfilling the DOE/NNSA's mission have the right and responsibility to report concerns relating to the environment, safety, health, security, fraud, waste, abuse or mismanagement of Department operations. The DOE/NNSA encourages communications between management and employees and has a zero tolerance for harassment, intimidation, discrimination, or any acts of retaliation against an employee for expressing/identifying concerns.

This report should not contain classified information and is subject to privacy act requirements


Nature of Concern:
Safety Health EEO Human Resources
Quality Security Environmental Workplace Violence
FraudWasteAbuse Management Mismanagement
Multiple Concerns Other

What do you believe may be the consequence(s) of your concern if it remains unresolved?

Personal Harm Damage/Loss Of Safety Loss Of Job
Personal Hazard Loss of Life or Injury Breech of Security

Where else have you reported your concern?

Why did you choose this avenue to report your concern?

Lack of Trust in Management Fear of Retaliation
Dissatisfaction with Corrective Action Lack of Response
Other

Describe your concern as clearly as possible


(Discuss anything that you think is relevant. Include what you believe caused the problem and what can be done to correct the situation. Provide names, dates, locations, witnesses, and all information you think is important to this concern.)

Date: *Name or Code Word** Phone #
*Correspondence Address

Your concerns will be sent to the DOE/NNSA Employee Concerns Program Manager via e-mail
 
*OPTIONAL
**If reporting anonymously, use a maximum of five characters. You may call the ECP Hotline at (800) 688-5713 for an update on the status of your concern by identifying yourself by your code word.
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