NHTSA Form 1685 FORM WB-RELEASE WHISTLEBLOWER RELEASE FORM

OMB Control 2127-XXXX

Expiration Date XX/XX/XXXX

Appendix B to Part 513- FORM WB-RELEASE

UNITED STATES DEPARTMENT OF TRANSPORTATION

NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (“NHTSA”)

The information requested on the WB-RELEASE form is voluntary. The WB-RELEASE form is for those potential whistleblowers who wish to provide prior written consent for the Agency to disclose information which could reasonably be expected to reveal the potential whistleblower’s identity. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. NHTSA estimates that completing and submitting this form will take approximately 15 minutes. The OMB Control Number for this information collection is 2127-XXXX. Please send comments to the Agency regarding the accuracy of this estimate and any suggestions for reducing this burden.

FORM WB-RELEASE

WHISTLEBLOWER RELEASE FORM

The purpose of this form is to provide prior written consent to NHTSA to disclose any information that you submit to NHTSA that could reasonably be expected to reveal your identity. NHTSA will only use the information you provide to assess any motor vehicle defect, noncompliance, or any violation or alleged violation of any notification or reporting requirement in 49 U.S.C. chapter 301, which is likely to cause unreasonable risk of death or serious physical injury

Pursuant to 49 U.S.C. § 30172, NHTSA shall not disclose any information that could reasonably be expected to reveal personal identity of a whistleblower except in only certain instances such as: (a) disclosure to a defendant or respondent in a public proceeding; (b) prior written consent is provided; or (c) information is received through another source and has authority under other law to release such information.

Please be advised that pursuant to 5 C.F.R. § 1320.5(b)(2)(i), an individual is not required to respond to this collection of information unless it displays a currently valid OMB Control Number. The OMB Control Number for this information collection is listed above.

Your submission of information to NHTSA is voluntary. Prior written consent is not required.

For more detailed information, please review the Notice of Whistleblower Rights and Protections, Privacy Act Statement, Submission Procedures and Completion Instructions below.

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 NHTSAWhistleblower@dot.gov 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;

• 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 whom 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.

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 whom such allegations are made or other entities.

CONSENT - I have read and understand the above information and authorize NHTSA to reveal any information submitted by me that could reasonably be expected to reveal my identity to persons at the organization or institution against whom 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.

I DO NOT CONSENT—I do not consent for NHTSA to disclose any information that I submit.

C. Prospective Whistleblower’s Signature
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 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 NHTSAWhistleblower@dot.gov, or a NHTSA attorney with whom you have previously been in contact.

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. NHTSA may disclose any information, including information provided by you, when it is required to be disclosed to a defendant or respondent in connection with a public proceeding instituted NHTSA. 49 U.S.C. § 30172(f)(1)(A). NHTSA may reveal such information if the whistleblower gives prior written consent. 49 U.S.C. § 30172(f)(1)(B). NHTSA may disclose such information if NHTSA receives the information through another source, such as during an inspection or investigation and has authority under other law to release the information. . 49 U.S.C. § 30172(f)(1)(C).

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. 30101 et. seq.).

The information requested on the WB-RELEASE form is voluntary. The WB-RELEASE form is for those potential whistleblowers who wish to provide prior written consent for the Agency to disclose information which could reasonably be expected to reveal the potential whistleblower’s identity. n.

The Agency anticipates that this form will be submitted to a dedicated email address or other method specifically designated on NHTSA’s website. NHTSA intends to treat the information as confidential under the provisions of 49 U.S.C. § 30172(f).

NHTSA Form 1685