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Request for Investigation or Inspection of Safety or Classified Information Security Violations.
DOE F 440. 2
Created Date: (5/18/2013)

U.S. Department of Energy

Request for Investigation or Inspection of Safety or Classified
Information Security Violations

This form is provided for use by any U.S. Department of Energy (DOE) contractor employee or representative thereof who (1) believes that a violation of a DOE safety regulation or DOE classified information security regulation or requirement has occurred and (2) requests that the DOE Office of Enforcement and Oversight initiate an inspection or investigation into the violation. This form is not intended for use in filing complaints that do not involve a violation of DOE regulations. Please be advised that information in your request, except your name and other identifying information about you, if you have indicated below that your request is to remain anonymous or confidential, will be provided to the appropriate DOE Headquarters and field office organizations as their cooperation will be needed in evaluating the request.

DO NOT use this form to report an emergency or immediately life-threatening condition.
DO NOT include any classified information.
1. DOE Site:
2. I am an (select one): Representative of Employees Employee
3. I work for/represent:
4. Is your request related to your employer or another contractor?

Employee Other Contractor

If other, specify the contractor:
5. Specific location where the violation or condition exists or occurred (e.g., building, facility, work area, laboratory/room number):
6. The violation or condition is:
One-Time Recurring Ongoing
 7. On what date did the violation or condition become known?
8. Describe the violation or condition. Include a description of the work activities involved, the number of employees exposed to or threatened by the violation/condition, and the potential impact of the condition/violation (e.g., injuries, spread of contamination, loss of control of material, number of individuals with unauthorized information access). Be as factual and detailed as possible but do not include any classified information. Attach additional sheets necessary and/or provide any relevant supporting documentation.
9. If possible, identify the specific DOE safety regulation, DOE classified information security regulation/requirement, and/or company procedures that may have been violated.
10. Did you observe the condition or violation yourself?
YesNo

If you did not observe the condition or violation, how did you find out about it?
11. Where else have you reported the condition or violation?

Immediate SupervisorCompany Safety RepresentativeCompany Security Representative
Company Employee Concerns ProgramUnion RepresentativeDOE Employee Concerns Program
NowhereOther (Specify)
12.Describe the results of efforts to resolve this issue through existing contractor and DOE mechanisms. Provide or reference any supporting documentation that may be available for review.
13.Select an option for handling your request (check one):

I wish to remain anonymous. I understand that this may limit DOE's ability to fully investigate the issue identified and I will not be notified of the outcome from my request.
I do not want my name to be revealed but the Office of Enforcement and Oversight may communicate with me regarding my request. My identity will be protected from all persons except Office of Enforcement and Oversight staff who have a need to know (please provide contact information below ).
My name may be revealed during communications about my request (please provide contact information below).
14.
Name:
Job Title:
Address:
(Street)
(City,State,Zip Code)
15.Telephone Number:
 16.E-mail Address:
 17.Date:
18. Preferred method of contact (check one): Mail E-Mail Telephone
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Link: The White House Link: USA.gov Link: Spanish USA.gov Link: E.gov Link: Information Quality Link: Freedom of Information Act