Get Va Form 10177, Employee Disclosure Form

The VA Form 10177, Employee Disclosure Form, provides a vital opportunity for employees to submit disclosures regarding potential wrongdoing or violations within the Department of Veterans Affairs. This guide will assist you in filling out the form online in a clear and straightforward manner.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Provide the date of submission in the designated field. This marks the official date of your disclosure.
3. In Part 1, fill in your personal information. Enter your name, optional mailing address, and contact numbers (home, office, and cell). Include your email address, current position title, series, grade, and the name and address of the VA facility where you are employed.
4. In Part 2, specify the name of the VA facility where the activity you are disclosing occurred, along with its address.
5. Move to Part 3, where you will detail your disclosure. Indicate how you know about the information you are disclosing (personal knowledge, information from other employees, or other sources). Identify the facility and organizational unit involved.
6. In Part 3, check all applicable types of agency wrongdoing you are alleging. If you select 'violation of law, rule, or regulation,' provide the specific details if possible.
7. Clearly describe the agency wrongdoing in the designated area, providing specific information about dates, locations, and the identities and positions of involved individuals. If you have any supporting documents, note them here.
8. In Part 4, choose whether you consent to the release of your identity. Provide an ink signature and the date you submitted the form.
9. Ensure all attached documents are noted in the space provided to create a complete submission package.

Begin filling out the VA Form 10177 online to submit your disclosure today.