OSC Form 12

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U.S. OFFICE OF SPECIAL COUNSEL
Form OSC-12 (2/5/06)

Reset Form

(202) 653-9125 / (800) 572-2249
OMB Control No. 3255-0002

INFORMATION ABOUT FILING A WHISTLEBLOWER DISCLOSURE
WITH THE
OFFICE OF SPECIAL COUNSEL

IMPORTANT
Before filling out this Office of Special Counsel (OSC) Disclosure of Information form, please
read the following sections about limitations on OSC’s jurisdiction over whistleblower disclosures.
Only the most frequently occurring impediments to OSC jurisdiction are described. OSC may not have
jurisdiction over you or your disclosure for other reasons not discussed below.

OSC WHISTLEBLOWER DISCLOSURE CHANNEL
The OSC Disclosure Unit serves as a secure channel that can be used to disclose ―
a violation of law, rule or regulation;
gross mismanagement;
gross waste of funds;
abuse of authority, or
substantial and specific danger to public health or safety.
OSC does not have authority to investigate the disclosures that it receives. The law provides
that OSC will (a) refer protected disclosures that establish a substantial likelihood of wrongdoing
to the appropriate agency head, and (b) require the agency head to conduct an investigation,
and submit a written report on the findings of the investigation to the Special Counsel.
If OSC finds no substantial likelihood that the information discloses one or more of the
categories of wrongdoing, the Special Counsel must: (a) inform the whistleblower of the reasons
why the disclosure may not be acted on further; and (b) direct the whistleblower to other
offices available for receiving disclosures.
OSC JURISDICTION
The Disclosure Unit has jurisdiction over federal employees, former federal employees, and
applicants for federal employment. It is important to note that a disclosure must be related to an
event that occurred in connection with the performance of an employee's duties and
responsibilities. The Disclosure Unit has no jurisdiction over disclosures filed by:
(over)

VISIT HTTP://WWW.OSC.GOV FOR MORE INFORMATION
ABOUT OSC JURISDICTION AND DISCLOSURE PROCEDURES

DISCLOSURE OF INFORMATION
Page ii

INFORMATION ABOUT FILING A WHISTLEBLOWER DISCLOSURE
WITH OSC (cont'd)

employees of the U.S. Postal Service and the Postal Rate Commission;
employees of the armed forces of the United States (i.e., non-civilian military
employees);
employees operating under federal grants; and
employees of federal contractors.
FIRST-HAND INFORMATION REQUIRED
In order to make a “substantial likelihood” finding (see previous page), OSC must be in
possession of reliable, first-hand information. OSC cannot request an agency head to conduct
an investigation based on an employee’s (or applicant's) second-hand knowledge of agency
wrongdoing. This includes information received from another person, such as when a fellow
employee informs you that he/she witnessed some type of wrongdoing. (Anyone with first-hand
knowledge of the allegations you want to report may file a disclosure in writing directly with
OSC.) Similarly, speculation about the existence of misconduct does not provide OSC with a
sufficient legal basis upon which to send a matter to the head of an agency. If you think that
wrongdoing took place, but can provide nothing more than unsubstantiated assertions, OSC will
not be able to go forward with the matter.
DE MINIMIS ALLEGATIONS
While an allegation might technically constitute a disclosure, OSC will not review or refer de
minimis or trivial matters.
ANONYMOUS SOURCES
While OSC will protect the identity of persons who make disclosures, it will not consider
anonymous disclosures. If a disclosure is filed by an anonymous source, the disclosure will be
referred to the Office of Inspector General in the appropriate agency. OSC will take no further
action.
MATTERS INVESTIGATED BY AN OFFICE OF INSPECTOR GENERAL
It is the general policy of OSC not to transmit allegations of wrongdoing to the head of the
agency involved if the agency’s Office of Inspector General has fully investigated, or is currently
investigating, the same allegations.
COMPLETED DISCLOSURE FORMS CAN BE SENT TO OSC BY MAIL, AT: DISCLOSURE UNIT, OFFICE OF
SPECIAL COUNSEL, 1730 M STREET, N.W. (SUITE 201), WASHINGTON, DC 20036-4505.
PLEASE KEEP A COPY OF DISCLOSURE MATERIALS PROVIDED TO OSC. REPRODUCTION CHARGES
UNDER THE FREEDOM OF INFORMATION ACT MAY APPLY TO REQUESTS PROCESSED BY OSC FOR
COPYING OF COPIES OF MATERIALS IN OSC FILES.

U.S. OFFICE OF SPECIAL COUNSEL

(202) 653-9125 / (800) 572-2249

DISCLOSURE OF INFORMATION
(Please print legibly or type and complete all pertinent items. Enter “N/A” (not applicable) or
“Unknown” where appropriate.)
PART 1: BACKGROUND INFORMATION
1. Name of person seeking OSC action:

Mr. (

)

Ms. (

)

Mrs. (

)

Miss (

)

_________________________________________________________________________
2. Status:
Current Federal employee (
Former Federal employee (

)
)

Applicant for Federal employment ( )
Other (please specify): _______________________
__________________________________________

3. Contact information:
Home or mailing address:

______________________________________________
______________________________________________

Telephone number(s):

(

) ____________________ (Home)

(

) ____________________ (Office)

(

) ____________________ (Cell)

Fax number:

(

) _________________

E-mail address:

______________________________________________

Ext.

_____

4. Current position, title, series, and grade:
_________________________________________________________________________
_________________________________________________________________________
5. Agency name: ____________________________________________________________
6. Agency address:
_________________________________________________________________________
_________________________________________________________________________
7. How did you first become aware that you could file a disclosure with OSC?
OSC brochure ( )
OSC poster ( )
OSC speaker ( )
OSC Web site ( )
Agency personnel office ( )
Union ( )
Co-worker ( )
News story ( )
Other (please describe): _____________________________________________________
Date (approximate): ___________________________________

DISCLOSURE OF INFORMATION
Page 2

8. If you are filing this complaint as a legal or other representative of the person making a
disclosure, please supply the following information:
Name / title of filer:

Mr. (

)

Ms. (

)

Mrs. (

)

Miss (

)

_________________________________________________________________________
9. Contact information:
Home or mailing address:

______________________________________________
______________________________________________

Telephone number(s):

(

) ____________________ (Home)

(

) ____________________ (Office)

Fax number:

(

) _________________

E-mail address:

______________________________________________

Ext.

_____

PART 2: DETAILS OF YOUR DISCLOSURE
1. I know about the information I am disclosing here based on (check all that apply):
I have personal and/or direct knowledge of events or records involved ( )
Other employees have told me about events or records involved ( )
Other source(s) ( )
(please explain): __________________________________________________
__________________________________________________
2. Please identify the U.S. government department or agency involved in your disclosure:
________________________________________________________________________
3. Please identify the organizational unit of the department or agency involved:
_________________________________________________________________________
4. Address of the organizational unit:
_________________________________________________________________________
5. Please identify the type of agency wrongdoing that you are alleging (check all that apply).
If you check “violation of law, rule, or regulation,” please provide, if you can, the particular
law, rule or regulation violated (by name, subject, and/or citation).
Violation of law, rule, or regulation (

) (please specify): ___________________________

_________________________________________________________________________
Gross mismanagement ( )
Gross waste of funds (
Substantial and specific danger to public health ( )
Substantial and specific danger to public safety ( )

)

Abuse of authority (

)

DISCLOSURE OF INFORMATION
Page 3

6. Please describe the agency wrongdoing that you are disclosing, indicating how the agency’s
actions fit within the type(s) of wrongdoing that you checked in item 5. (Be as specific as
possible about dates, locations and the identities and positions of all persons named. Also,
please attach any documents that might support your disclosure. Continue on a separate
sheet of paper if you need more space.)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

DISCLOSURE OF INFORMATION
Page 4

PART 3: OTHER ACTIONS YOU ARE TAKING ON YOUR DISCLOSURE

1. I have previously disclosed (or am disclosing) the violations alleged here to (complete all
that apply):
(

) Inspector General of department / agency involved

Date: ___/___/____

(

) Other office of department / agency involved
(please specify):
_________________________________________________

Date: ___/___/____

(

) Department of Justice

Date: ___/___/____

(

) Other Executive Branch / department / agency
(please specify):
_________________________________________________

Date: ___/___/____

(

) General Accounting Office (GAO)

Date: ___/___/____

(

) Congress or congressional committee
(please specify member or committee):

Date: ___/___/____

(

) Press / media (newspaper, television, other)
(please specify):

Date: ___/___/____

2. If you disclosed the information reported here through any other channel described in
question 1, above, what is the current status of the matter?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

PART 4: CONSENT, CERTIFICATION, AND SIGNATURE
Do you consent to the disclosure of your name to others outside the Office of Special Counsel if
it becomes necessary in taking further action on this matter?
I consent to disclosure of my name:
___________________________________
Signature

____________________
Date

I do not consent to disclosure of my name:
___________________________________
Signature

____________________
Date

DISCLOSURE OF INFORMATION
Page 5

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
$10,000, imprisonment for up to five years, or both. 18 U.S.C. § 1001.
__________________________________________
Signature

_______________________
Date

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 on 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 prohibited personnel practices or other prohibited activity has been filed;

2.

to disclose information needed by the Office of Personnel Management (OPM) 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 anti-discrimination laws;

4.

to the MSPB or the President, when seeking disciplinary action;

5.

to the involved agency, the MSPB, OPM, or the President when OSC has reason to believe that a prohibited
personnel practice 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 (without identifying the complainant unless OSC has the complainant’s
consent) as needed to conduct an investigation; obtain an agency investigation and report on information
disclosed to the OSC whistleblower disclosure channel; or to give notice of the status or outcome of the
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;

9.

to the Office of Management and Budget (OMB) for certain legislative coordination and clearance purposes;

DISCLOSURE OF INFORMATION
Page 6

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 needed by the Department of Justice for certain litigation purposes;

14.

to provide information needed by courts or adjudicative bodies 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.

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 (at 5 U.S.C. § 1213) to
receive disclosures from current or former federal employees, or applicants for federal
employment, alleging possible wrongdoing by federal agencies. The information will be used by
OSC to determine whether the facts establish that: (a) OSC has jurisdiction over the subject of
the disclosure; (b) there is a substantial likelihood that the facts indicate a violation of law, rule,
or regulation; gross mismanagement; a gross waste of funds; an abuse of authority: or a
substantial and specific danger to public health or safety; and (c) referral for investigation by the
agency involved, or other appropriate action is warranted. The reporting burden for this
collection of information is estimated to be an average of one hour 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 U.S. Office of Special Counsel, Legal Counsel and Policy Division, 1730 M Street,
N.W. (Suite 201), Washington, DC 20036-4505. Use of this form to report disclosures of
information is not mandatory. As indicated in part 4 of the form, filers may request that OSC
maintain their name in confidence.