Capitol Security Info - Portal Submission

Capitol Security Info

Note: Fields marked with an * are required.

Are you willing to share your identity with us so that we may follow up with you? *

Yes No

Contact Information

First Name

Last Name

Street Address

City

State

Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

ERROR ON FIELD - select

Email Address

Phone Number

What are these options?

Individuals who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option "Voice" is a standard audible telephone.

Do you have a lawyer [or other representative] for this matter, and do you prefer we communicate through them? *

Yes, please communicate with me through my lawyer or other representative I have a lawyer or other representative, but please communicate with me directly No, I am not working with a lawyer or other representative

Lawyer Details

Lawyer [or other representative] Name

Lawyer [or other representative] Phone Number

Employment Details

Employment Type: *

U.S. Federal Government U.S. Federal Government U.S. Military U.S. Military U.S. Government Contractor or Grantee U.S. Government Contractor or Grantee State, Local, or Tribal Government State, Local, or Tribal Government Private Sector Private Sector Retired Retired Self-Employed Self-Employed Unemployed Unemployed Other (if other, please list) Other (if other, please list)

If you are employed, please list your employer

Complaint Details

ERROR ON FIELD - checkbox-list

Other Concern

Complaint Description (3000 word count limit) *

Please describe your goals in working with our Office *

Have you filed your concerns elsewhere or contacted another government office about this allegation? *

Yes No

Where else have you filed, and/or which other government offices have you communicated with about this allegation, and what is the status of any related investigation(s)?

Do you have colleagues that can support your concerns and are willing to communicate with our office?

Do you believe you have experienced or been threatened with retaliation in connection with your concerns? *

Yes No

Please describe any retaliation you have experienced or been threatened with in connection with your concern(s)

Would you like to be contacted regarding this submission? *

Yes

No

Human Validation

Google Recaptcha Label