SAMPLE WHISTLEBLOWER RETALIATION COMPLAINTNOTE: Although not required, the SPB encourages individuals who file awhistleblower retaliation complaint to utilize the format provided below to facilitateprocessing of their complaint.

SAMPLEWHISTLEBLOWER RETALIATION COMPLAINTEmployee’s NameClassificationMailing AddressINATURE OF THE COMPLAINTI have been retaliated against in my employment as a [Job Title] with the [AppointingPower], at [Work-Site Address], as a result of my having reported improper governmentalactivities [OR, as a result of my having refused to obey an illegal order or directive] [OR,as a result of my having reported improper governmental activities and for having refusedto obey an illegal order or directive]. The entity [and/or persons] that have retaliatedagainst me is as follows: [Identify the appointing power, if applicable, as well as eachindividual employee, by name and job title, if applicable]II STATEMENT OFFACTS[List in chronological or some other logical order, in consecutively numberedparagraphs, the following information: (1) the improper governmental activity youreported, or the illegal order or directive you refused to obey; (2) the date(s) youreported the improper governmental activity, or refused to obey the illegal order ordirective; (3) the person(s) to whom you reported the improper governmental activity, orto whom you indicated you would not obey the illegal order or directive; (4) the acts ofreprisal or retaliation you experienced as a result of your complaint(s) of impropergovernmental activity, or refusal(s) to obey an illegal order or directive; (5) the date onwhich you experienced each act of reprisal or retaliation; and (6) all information youpossess that demonstrates each act of reprisal or retaliation occurred as a result of yourreport(s) of improper governmental activity, or your refusal(s) to obey an illegal order ordirective.]For example:1.Between April 1, 1998 and continuing through to the present day, I have beenemployed as an Associate Budget Analyst with the California Department of

Corrections and Rehabilitation (CDCR or Department), at Corcoran State Prison(CSP), Corcoran, California. My duties in that capacity require me to, among otherthings, review and approve Travel Expense Claims (TEC), and review overtimeusage. Prior to my whistleblowing, I had never received a written reprimand or anotice of adverse action by any supervisor or manager.2.Sometime between April 15, 2011 and May 2, 2011, I verbally informed myimmediate supervisor, Staff Services Manager I Arnold Supervisor (Supervisor),that Correctional Lieutenant Jane Doe (Doe) had submitted three separate TECsthat contained fraudulent information.On one TEC, Doe requestedreimbursement for 250 miles travel in her private vehicle, even though she hadtraveled in a state vehicle. On the second TEC, Doe claimed reimbursement forthree days of per diem, but her trip had only lasted two days. On the third TEC,Doe claimed reimbursement for payment for an off-site training course, but theDepartment had paid for the course, not Doe. Supervisor informed me that hewould look into the matter, and get back to me.3.On May 7, 2011, Doe approached me while I was speaking to my co-worker,Sam Smith, an Associate Budget Analyst, and said, “Why are you trying to getme in trouble? I thought we were friends. No one, including you, is a saint. Ifyou don’t drop this whole TEC thing, I’ll see to it that you live to regret trying to getme in trouble.” Smith witnessed Doe’s threat. (Exhibit 1, Smith Declaration.)4.On that same date, I reported this conversation to Supervisor, but he only saidthat I shouldn’t take the threat seriously, because Doe was just upset. When Iasked what was being done about the false TECs, Supervisor told me not toworry about it, and that the matter had been “handled.”

5.On June 10, 2011, I informed Supervisor by email that Correctional Officer JohnJohnson (Johnson) had, on May 15, 2011, claimed four hours of overtime, eventhough he had only worked one hour of overtime on that date. (Exhibit 2,6/10/11 email to Supervisor.) Supervisor informed me that he would look intothe matter, and get back to me. (Exhibit 3, 6/11/11 email from Supervisor.)6.Having heard nothing from Supervisor regarding the Johnson matter, on July 6,2011, I contacted his immediate supervisor, Staff Services Manager II MaryManager (Manager) and told her what I had earlier reported to Supervisor.(Exhibit 4, 7/6/11 email to Manager.) Manager stated that she was unaware of thesituation, and she would look into it and get back to me within the week. I alsoasked her what had ever happened about Doe’s false TECs, but Manager told methat she knew nothing about that situation either. (Exhibit 5, 7/7/11 exchange ofemails.)7.On July 8, 2011, Supervisor called me into his office. After I entered, he closedthe office door and, in an angry manner, accused me of “going behind his back” toManager about Doe and Johnson. When I said that I was just trying to follow- upon those matters because he had never told me what had occurred, he yelled thatI was not a “team player,” that “everything was working out fine until I opened mybig mouth,” and that I had “needlessly gotten two good people in serious troubleover simple mistakes that anyone could have made.” When I told him that I wasjust doing my job, he said, “We’ll just see how long you have a job to do,” and thentold me to “get the hell out of his office.”8.On that same date, I emailed Manager what Supervisor had said. Manager toldme she was going to refer the matter to Warden William Williams (Williams).(Exhibit 6, 7/8/11 emails to and from Manager.)

9.On July 9, 2011, Doe telephoned me at my home and told me that she wasgoing to do everything in her power to see that I was fired.10.On August 2, 2011, Supervisor called me into his office and gave me a writtencounseling memorandum, which indicated that I had not been processing myassignments in a timely manner, but it did not provide any specifics.Thememorandum also stated that I would be disciplined if my performance didnot improve.The memorandum further indicated that Supervisor would nolonger permit me to work a modified work schedule, where I was permitted toarrive at work 10 to 15 minutes past my regularly scheduled start time(provided I made up the time at the end of the day) in order to accommodatemy child’s day care schedule. (Exhibit 7, 8/2/11 counseling memorandum.)11.I refused to sign the counseling memorandum, because the accusationsconcerning my work performance were patently false.The fact that thecounseling memorandum provides no specifics and that I have never receivedany reprimands before I made my complaints demonstrates that it is retaliatory.I have consistently received above-average to outstanding performanceevaluations, and my most recent performance evaluation for 2010 rated me as“outstanding” overall. (Exhibit 8, Copies of my Performance Evaluations for2007, 2008, and 2009.)12.On that same date, I complained to Manager about Supervisor’s actions.Once again, she told me that she would refer the matter to Warden Williams.Despite Manager’s frequent assertions that she would refer the matter toWarden Williams, I was never contacted by anyone as a result of these

referrals. Accordingly, I believe that Manager ignored my complaints.13.Shortly after this incident, I began to experience a great deal of emotionaltrauma as a result of Supervisor’s and Doe’s actions, and Manager’s inaction.Because of this, I sought treatment from a psychologist through my Health CareProvider. (Exhibit 9, Evaluations of Dr. Lee, dated August 5, 15, September 7,14, and October 1, 15, 2010.)14.On September 5, 2010, Supervisor gave me an early performance evaluation for2011, where I was rated as “standard” and “needs improvement.”His statedreasons for downgrading my evaluation was because I was not completing myassignments in a timely manner, refused to accept instruction, and was regularlylate for work. He also told me that my merit salary increase had been denieddue to my poor performance. (Exhibit 10, 2011 Performance Evaluation,and Exhibit 11, denial of merit salary increase.) However, Supervisor onceagain failed to provide examples of assignments I was allegedly not completingin a timely matter or evidence that I was regularly late for work.15.As I left Supervisor’s office, Doe was standing outside. As I walked past her, shesaid, “See what happens when you try to screw around with other people’slives.”16.It is my belief that Supervisor, in collusion with Doe, retaliated against mebecause I reported Doe’s fraudulent TECs to Manager. That retaliation included:(A)Supervisor’s discontinuance of my modified work schedule.(B)The unfavorable early 2011 performance evaluationI received from Supervisor.(C)17.The denial of my merit salary increase for 2012.It is also my belief that Manager approved of the above- listed retaliatory acts

because she failed to take any action to correct these threats and improperpersonnel actions, even though I had specifically informed her of thoseimproper actions.IIIDAMAGES AND RELIEF REQUESTED[You must specify all damages and relief you are seeking (e.g., backpay,benefits, transfer, promotion, reinstatement, emotional distress).]For example:1.I am requesting that my merit salary increase for 2012 be approved, and that Ireceive all additional money I would have received, plus interest, from the date ofdenial until the present.2.I am requesting that I be transferred to an Associate Budget Analyst position atthe Substance Abuse Treatment Facility, Corcoran, California.3.I am requesting that the counseling memorandum, be expunged from allDepartment records and files.4.I am requesting that the 2011 Performance Appraisal be expunged from alldepartment records and files.5.I am requesting that I again be permitted to work a modified work schedule toaccommodate my child’s day care schedule.IVDISCIPLINARY ACTION REQUESTED[If you wish disciplinary action to be taken against any individual, you must specificallyidentify that individual, and clearly state the facts constituting the cause or causes foradverse action in such detail as is reasonably necessary to enable the accusedemployee to prepare a defense to those allegations. You should also indicate whatspecific discipline you want imposed on each such individual, and you must include thebusiness address of each individual.]

(1)I am requesting that disciplinary action be taken against Staff Services Manager IArnold Supervisor. His business address is: [List business address].(2)I am requesting that disciplinary action be taken against Correctional LieutenantJane Doe. Her business address is: [List business address].(3)I am requesting that disciplinary action be taken against Staff Services Manager IIMary Manager. Her business address is: [List business address].V.SWORN STATEMENTI declare, under penalty of perjury under the laws of the State of Californiathat the foregoing is true and correct to the best of my knowledge and belief.Dated:Name/Title

Enclosures: Exhibits and Supporting Materials[You must include all documents in your possession, custody, or control that support yourcontention that you have been retaliated against as a result of your having reportedimproper governmental activities, or for your having refused to obey an illegal order ordirective.This includes any witness declarations or affidavits that you can obtain,because you will not have the opportunity to conduct written discovery prior to an informalhearing .]