OSC Form 14

U.S. OFFICE OF SPECIAL COUNSEL
Form OSC-14 (03-05)

USERRA Unit: (202) 254-3620
OMB Control No. 3255-0002

COMPLAINT OF POSSIBLE VIOLATION OF
THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA)

INFORMATION ABOUT FILING A USERRA COMPLAINT WITH OSC

This complaint form may be used to file complaints alleging violations of The Uniformed Services
Employment and Reemployment Rights Act of 1994 (USERRA), 38 U.S.C. § 4301 et seq., by federal
employees or applicants for federal employment. While it is not required that this complaint form be
used, use of this form will be helpful to OSC in expediting the processing and investigating of
complaints. Please complete the information requested below as fully and accurately as possible.
SEND COMPLETED COMPLAINT FORMS TO:
By Mail:

USERRA Unit
Office of Special Counsel
1730 M Street, N.W. (Suite 218)
Washington, DC 20036-4505

By Fax:

(202) 653-5151

Electronically:

WWW.OSC.GOV (AT “FILE COMPLAINTS ONLINE”)

PLEASE KEEP A COPY OF YOUR COMPLAINT, ANY SUPPORTING DOCUMENTATION, AND ANY ADDITIONAL
ALLEGATIONS SENT IN WRITING TO OSC NOW, OR AT ANY TIME WHILE YOUR COMPLAINT IS PENDING.
REPRODUCTION CHARGES UNDER THE FREEDOM OF INFORMATION ACT MAY APPLY TO ANY REQUEST YOU

INFORMATION ABOUT USERRA
USERRA prohibits discrimination against persons because of their service in the Armed Forces, Armed Forces
Reserve, the National Guard, and other uniformed services. USERRA prohibits an employer from denying any benefit
of employment on the basis of an individual’s membership, application for membership, performance of service,
application for service, or obligation for service in the uniformed services. USERRA also protects the employment and
reemployment rights of service members who are absent from their civilian employment due to military service or
training.
Pursuant to a demonstration project established by the Veterans Benefits Improvement Act of 2004 (P.L. 108-454),
OSC, rather than the Department of Labor’s Veterans Employment and Training Service, has authority to investigate
federal sector USERRA claims brought by persons whose social security number ends in an odd-numbered digit
(1,3,5,7, or 9). Furthermore, regardless of a person’s social security number, OSC has the authority to investigate
all federal sector USERRA claims containing a related prohibited personnel practice allegation over which OSC has
jurisdiction. (Please visit www.osc.gov and click on the “Prohibited Personnel Practices” link to learn more about
personnel practices that are prohibited in the federal workplace.)
OSC is administering the demonstration project, which began on February 8, 2005, and ends on September 30, 2007.
If you have any questions about filling out this form or filing a USERRA complaint with OSC, please contact OSC’s
USERRA Unit by telephone at (202) 254-3620 or via e-mail at [email protected].

VISIT WWW.OSC.GOV
FOR MORE INFORMATION ABOUT USERRA
U.S. OFFICE OF SPECIAL COUNSEL

(202) 254-3620

COMPLAINT OF POSSIBLE VIOLATION OF USERRA
Page 2 of 8

COMPLAINT OF POSSIBLE VIOLATION OF USERRA
(Please print legibly or type and complete all pertinent items. Enter "N/A" (Not Applicable) or "Unknown" where appropriate.
(If more space is needed, use Continuation Sheet.)

PART 1: COMPLAINANT INFORMATION
1. Name of person whose USERRA rights were allegedly violated: Mr. ( ) Ms. ( ) Mrs. ( ) Miss ( )
______________________________________________________________________________________
2. Home Mailing Address: ___________________________________________________________________
______________________________________________________________________________________
3. Last digit in your social security number: ____
4. Contact information:
Telephone number(s):
Fax number:
E-mail address:

(
) ___________________ (Home)
(
) ___________________ (Office) Ext. ______
(
) ___________________
____________________________________________

5. Uniformed Services Information:
A. Branch of service (check all that apply):
____ Army
____ Navy
____ Air Force
____ Marine Corps
____ Coast Guard
____ Public Health Services

____ Reserves
____ National Guard

National Guard or Reserve Unit: __________________________________
Address:
__________________________________
__________________________________
Telephone:
(
) ____________________________
B. Nature of service
____ Active Duty
____ Initial Active Duty for Training
____ Active/Inactive Duty fro Training
____ Examinee/Rejectee
____ Other: __________________________________
____ Not Applicable

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C. Service Dates:
1. (a) Service from _____________ to _____________.
or
(b) Date of examination for service or rejection for service: ___________
D. Type of Discharge:
____ Honorable
____ Honorable conditions
____ Entry level
____ Uncharacterized
____ Medical
____ Other: _________________________

____ Other than honorable
____ Dishonorable
____ Bad Conduct

____ Not applicable
6.

Agency/Employer Name:
Address:
Telephone:

______________________________________________________________
__________________________________
__________________________________
__________________________________

7. What other action(s), if any, have you taken to appeal, grieve, or report this matter under any other
procedure? (Check all that apply.)
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(

) None, or not applicable
) Appeal filed with Merit Systems Protection Board (MSPB)
) Petition for reconsideration of initial decision filed with MSPB
Initial Decision No. __________________________________
) USERRA claim filed with VETS (Department of Labor)
(Form VETS/USERRA/VP-1010)
) Grievance filed under agency grievance procedure
) Grievance filed under negotiated grievance procedure
) Matter heard by arbitrator under grievance procedure
) Matter is pending in arbitration
) Discrimination complaint filed with agency
) Agency or Administrative Judge (AJ) decision on discrimination
complaint appealed to Equal Employment Opportunity Commission
) Appeal filed with the Office of Personnel Management
) Unfair Labor Practice (ULP) complaint filed with the
Federal Labor Relations Authority General Counsel
) Lawsuit filed in Federal Court
Court name: __________________________________________
) Reported matter to agency Inspector General
) Reported matter to Member of Congress
Name of Senator or Representative: _______________________
) Other (specify): ________________________________________

Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________
Date: ____________________

COMPLAINT OF POSSIBLE VIOLATION OF USERRA
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8. How did you first become aware that you could file a complaint with OSC?
(
(
(

) OSC Web site
( ) OSC speaker
( ) OSC brochure
( ) OSC poster
) news story
( ) agency personnel office ( ) union
( ) co-worker
) other (please describe): ____________________________________________________________
Date (approximate): ___________________________________________

PART 2: BRIEF SUMMARY OF ALLEGED VIOLATION(S)
ARTPART 1: PROHIBITED POLITICAL ACTIVITY (GENERAL)

9. Name of the person(s) who allegedly violated USERRA (“Subject”): ________________________________
10. Position/Title of the subject(s): ____________________________________________________________
11. Briefly describe the alleged USERRA violation:
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_______________________________________________________________________________
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COMPLAINT OF POSSIBLE VIOLATION OF USERRA
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_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
12. Do you also believe the employer may have committed a prohibited personnel practice(s)? If so, briefly
describe the alleged prohibited personnel practice(s):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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COMPLAINT OF POSSIBLE VIOLATION OF USERRA
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PART 3: CONSENT TO CERTAIN DISCLOSURES OF INFORMATION
OSC asks everyone who files a complaint alleging a violation of USERRA to select one of three Consent
Statements shown below. IF YOU DO NOT SELECT ONE OF THE THREE CONSENT STATEMENTS
BELOW, OSC WILL ASSUME THAT YOU HAVE SELECTED CONSENT STATEMENT 1. Please: (a) select
and sign (or check, if filing electronically) one of the Consent Statements below; and (b) keep a copy of the
Consent Statement you select (as well as a copy of all documents that you send to OSC) for your own records.
If you initially select a Consent Statement that restricts OSC's use of information, you may later select a less
restrictive Consent Statement. If your selection of Consent Statement 2 or 3 prevents OSC from being able to
conduct an investigation, an OSC representative will contact you, explain the circumstances, and provide you
with an opportunity to select a less restrictive Consent Statement.
You should be aware that the Privacy Act allows information in OSC case files to be used or disclosed for certain
purposes, regardless of which Consent Statement you sign. See 5 U.S.C. § 552a(b). Information about certain
circumstances under which OSC can use or disclose information under the Privacy Act appears on the next
page.
(Please sign one)
Consent Statement 1
I consent to OSC’s communication with the pertinent individuals involved in my complaint. I agree to allow OSC
to disclose my identity as the complainant, and information from or about me, if OSC decides that such
disclosure is needed to investigate the allegation(s) in my complaint. I understand that regardless of the
Consent Statement I choose, OSC may disclose information from my complaint file when permitted by the
Privacy Act (including circumstances summarized in Part 5, below).
___________________________________________________
Complainant's Signature for Consent Statement 1

_______________________________
Date Signed

Consent Statement 2
I consent to OSC’s communication with the pertinent individuals involved in my complaint, but I do not agree to
allow OSC to disclose my identity as the complainant. I agree to allow OSC to disclose only information from or
about me, without disclosing my name or other identifying information, if OSC decides that such disclosure is
needed to investigate the allegation(s) in my complaint. I understand that in some circumstances OSC could not
maintain my anonymity while communicating with the pertinent individuals. In such cases, I understand that this
request for confidentiality might prevent OSC from taking further action on my complaint. I also understand that
regardless of the Consent Statement I choose, OSC may disclose information from my complaint file when
permitted by the Privacy Act (including circumstances summarized in Part 5, below).
___________________________________________________
Complainant's Signature for Consent Statement 2

_______________________________
Date Signed

Consent Statement 3
I do not consent to OSC’s communication with the pertinent individuals involved in my complaint. I understand
that if OSC decides that it cannot investigate the allegation(s) in my complaint without communicating with these
individuals, my lack of consent will probably prevent OSC from taking further action on the complaint. I
understand that regardless of the Consent Statement I choose, OSC may disclose information from my
complaint file when permitted by the Privacy Act (including circumstances summarized in Part 5, below).
___________________________________________________
Complainant's Signature for Consent Statement 3

_______________________________
Date Signed

COMPLAINT OF POSSIBLE VIOLATION OF USERRA
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PART 4: CERTIFICATION AND SIGNATURE
I certify that all of the statements made in this complaint (including any continuation pages) are true,
complete, and correct to the best of my knowledge and belief. I understand that a false statement or
concealment of a material fact is a criminal offense punishable by a fine of up to $250,000, imprisonment
for up to five years, or both. 18 U.S.C. § 1001.
___________________________________________________
Signature

_______________________________
Date Signed

PART 5: PRIVACY ACT / PAPERWORK REDUCTION ACT STATEMENTS

Routine Uses. Limited disclosure of information from OSC files is needed to fulfill OSC's investigative,
prosecutorial, and related responsibilities. OSC has described 18 routine uses for information in its files in the
Federal Register (F.R.), at 66 F.R. 36611 (July 12, 2001), and 66 F.R. 51095 (October 5, 2001). A copy of the
routine uses is available from OSC upon request. A summary of the routine uses appears below.
OSC may disclose information from its files in the following circumstances:
1. to disclose that an allegation of a prohibited personnel practices or other prohibited activity has been
filed;
2. to disclose information to the Office of Personnel Management (OPM) as needed for inquiries involving
civil service laws, rules or regulations, or to obtain an advisory opinion;
3. to disclose information about allegations or complaints of discrimination to entities concerned with
enforcement of antidiscrimination laws;
4. to the MSPB or the President, when seeking disciplinary action;
5. to the involved agency, MSPB, OPM, or the President when OSC has reason to believe that a prohibited
personnel practice has occurred, exists, or is to be taken;
6. to disclose information to Congress in OSC's annual report;
7. to disclose information to third parties as needed to conduct an investigation; obtain an agency
investigation and report on information disclosed to OSC's whistleblower disclosure channel; or to give
notice of the status or outcome of an investigation;
8. to disclose information as needed to obtain information about hiring or retention of an employee;
issuance of a security clearance; conduct of a security or suitability investigation; award of a contract; or
issuance of a license, grant, or other benefit;

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9. to the Office of Management and Budget (OMB) for certain legislative coordination and clearance
purposes;
10. to provide information from an individual's record to a congressional office acting pursuant to the
individual's request;
11. to furnish information to the National Archives and Records Administration for records management
purposes;
12. to produce summary statistics and work force or other studies;
13. to provide information to the Department of Justice as needed for certain litigation purposes;
14. to provide information to courts or adjudicative bodies as needed for certain litigation purposes;
15. to disclose information to the MSPB as needed in special studies authorized by law;
16. for coordination with an agency's Office of Inspector General or comparable entity, to facilitate the
coordination and conduct of investigations and review of allegations;
17. to news media or the public in certain circumstances (except when the Special Counsel determines that
disclosure in a particular case would be an unwarranted invasion of personal privacy); and
18. to the Department of Labor and others as needed to implement the Uniformed Services Employment
and Reemployment Rights Act of 1994, and the Veterans’ Employment Opportunities Act of 1998.
If OSC officials believe that disclosure may be appropriate in a situation not covered by one of OSC's routine
uses, or one of the 11 other exceptions to the Privacy Act's general prohibition on disclosure, OSC will seek
written authorization from the complainant permitting the disclosure.
Purposes, Burdens, and Other Information. An agency may not conduct or sponsor a collection of information,
and persons may not be required to respond to a collection of information, unless it: (a) has been approved by
OMB; and (b) displays a currently valid OMB control number. The information in this form is collected pursuant
to OSC's legal responsibility to investigate certain federal sector USERRA allegations pursuant to section 204 of
the Veterans’ Benefits Improvement Act of 2004 (P.L.108-454) and 38 U.S.C. § 4301 et seq. The information will
be reviewed by OSC to determine whether the facts establish its jurisdiction over the subject of the complaint,
and whether further investigation is warranted. The reporting burden for this collection of information is
estimated to be an average of 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering the data needed, and completing and reviewing the form. Please send any
comments about this burden estimate, and suggestions for reducing the burden, to the Office of Special
Counsel, Legal Counsel and Policy Division, 1730 M Street, N.W. (Suite 218), Washington, DC 20036-4505.