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OMB Control No: 2127-0767	ICR Reference No: 202412-2127-008
Status: Active	Previous ICR Reference No: 202309-2127-001
Agency/Subagency: DOT/NHTSA	Agency Tracking No:
Title: Whistleblower Program Forms
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/14/2025
	Date Received in OIRA: 12/19/2024
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2028	36 Months From Approved
Responses	102	0	0
Time Burden (Hours)	791	0	0
Cost Burden (Dollars)	285,285	0	0

Abstract: This information collection request (ICR) relates to three new forms necessary for the efficient operation of the National Highway Traffic Safety Administration’s (NHTSA) whistleblower program, as established by 49 U.S.C. § 30172 (the Whistleblower Act). The Whistleblower Act authorizes the Secretary of Transportation (the Secretary) to pay an award to eligible whistleblowers who voluntarily provide original information, if the information provided leads to the successful resolution of a covered action. The three forms are the WB-INFO form, the WB-AWARD form, and the WB-RELEASE form. All of the information collections are collected on an as-needed basis. One of the information collections is completely voluntary and the other two are voluntary, but required to receive a benefit. Under the final rule, a potential whistleblower is required to submit a WB-INFO form and to submit a WB-AWARD form in order to qualify for a whistleblower award. A potential whistleblower may choose to voluntarily submit the WB-RELEASE form. Only minor changes, for clarity, were made to the forms in the final rule. The WB-INFO form will be used to permit NHTSA and its staff to collect information from potential whistleblowers about themselves, their legal representatives, and their allegations relating to any potential violation of the Safety Act or regulation thereunder. If a potential whistleblower proceeds anonymously, the individual must have a legal representative. That legal representative will retain their client’s signed WB-INFO form. The WB-AWARD form will permit NHTSA to collect information relating to a claimant’s eligibility for an award. This will allow NHTSA’s Administrator to determine claims for whistleblower awards. The WB-RELEASE form will provide a means for the potential whistleblower to provide consent for NHTSA to disclose information which could reasonably be expected to reveal the identity of the potential whistleblower. Being able to disclose this information may allow NHTSA to open a public investigation or proceed more efficiently with an investigation into the potential whistleblower’s allegations. The likely respondents to the forms (the WB-INFO, the WB-AWARD, and the WB-RELEASE form) are those employees or contractors of motor vehicle manufacturers, part suppliers, and dealerships who wish 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 requirement of the Safety Act or regulation thereunder. The anticipated recipients of the WB-INFO, WB-AWARD and WB-RELEASE forms are those individuals at NHTSA who have a need to know the information. This may include attorneys in NHTSA’s Office of the Chief Counsel and staff in NHTSA’s Office of Enforcement.

Authorizing Statute(s): US Code: 49 USC 30172 Name of Law: the Whistleblower Act

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2127-AL85	Final or interim final rulemaking	89 FR 101952	12/17/2024

Federal Register Notices & Comments
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Optional Private Counsel for Binding Nondisclosure Agreement
WB-AWARD-Individual with Legal Representative	NHTSA Form 1686
WB-INFO- Individual with Legal Representative	NHTSA Form 1684
WB-INFO-Individual	NHTSA Form 1684
WB-RELEASE-Individual	NHTSA Form 1685
WB-RELEASE-Individual with Legal Representative	NHTSA Form 1685

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	102	102
Annual Time Burden (Hours)	791	791
Annual Cost Burden (Dollars)	285,285	285,285

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is the implementation of a new program. NHTSA estimates that the burden hours will be 750 hours for the WB-INFO form, 11.25 hours for the WB-RELEASE form, 20 hours for the WB-AWARD form, and 10 hours for private counsel to review a binding nondisclosure agreement. The estimated annual burden hour total for this information collection is 791 hours (rounded).

Annual Cost to Federal Government: $11,382

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Dan Rabinovitz 202 366-8534

View ICR - OIRA Conclusion