OSC Form 11

U.S. OFFICE OF SPECIAL COUNSEL
Form OSC-11 (09/30/12)

(202) 254-3600 / (202) 254-3670 / (800) 872-9855
OMB Control No. 3255-0002

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE
OR
OTHER PROHIBITED ACTIVITY

IMPORTANT
Before filling out this Office of Special Counsel (OSC) form, please read the following information
about: (1) the required complaint format; (2) the scope of OSC's jurisdiction; and (3) certain
OSC policies. OSC cannot investigate a complaint if it lacks jurisdiction over the subject
matter. Further, filing a complaint with OSC will not extend any time limits that may exist under any
other complaint procedures that may be available. It is import ant, therefore, that you consider
whether OSC may lack jurisdiction over your complaint.
If you plan to file a complaint alleging reprisal for whistleblowing, important information about the
elements required by law to establish such a violation is provided in Part 2 of this form (at page 4).
INFORMATION ABOUT FILING A COMPLAINT WITH OSC
Required Complaint Form. Complaints alleging a prohibited personnel practice, or a prohibited activity other than a
Hatch Act violation, must be submitted on this form . OSC will not process comp laints (e xcept a complaint alleging
only a Hatch Act violation) that are not submitted on this form. OSC w ill return the material received, with a blank
complaint for m to complete and return to OSC. The complaint will be considered to be filed on the date on which
OSC receives the completed form, 5 C.F.R. § 1800.1, as amended.
No OSC Jurisdiction. OSC has no jurisdiction over complaints filed by employees of –
• the Central Intelligence Agency, Defense Intelligence Agency, National Security Agency, or other
intelligence agency excluded from coverage by the President;
• the armed forces of the United States (i.e., uniformed military employees);
• the General Accounting Office;
• the Postal Rate Commission; and
• the Federal Bureau of Investigation.
Limited OSC Jurisdiction. OSC has jurisdiction over certain types of complaints filed by employees of some
agencies, as follows –
• Federal Aviation Administration employees alleging reprisal for whistleblowing;
• employees of government corporations listed at 31 U.S.C. § 9101 alleging reprisal for whistleblowing;
• U.S. Postal Service employees alleging nepotism; and
• Transportation Security Administration (TSA) employees alleging reprisal for whistleblowing: TSA nonscreener employees may file complaints alleging retaliation for protected whistleblowing under 5 U.S.C. §
2302(b)(8). OSC will process these complaints under its regular procedures, including filing petitions with
the Merit Systems Protection Board, if warranted. TSA security screeners may also file complaints alleging
retaliation for protected whistleblowing under 5 U.S.C. § 2302(b)(8) pursuant to a Memorandum of
Understanding (MOU) between OSC and TSA executed on May 28, 2002. The MOU and TSA Directive
HRM Letter No. 1800-01 provide OSC with authority to investigate whistleblower retaliation complaints from
screeners and recommend that TSA take corrective and/or disciplinary action when warranted. Additional
information on OSC procedures for reviewing security screener whistleblower complaints under the MOU is
available at http://www.osc.gov/tsa-info.htm.
(over)

VISIT WWW.OSC.GOV
FOR MORE INFORMATION ABOUT OSC JURISDICTION AND COMPLAINT PROCEDURES

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page ii

INFORMATION ABOUT FILING A COMPLAINT WITH OSC (cont'd)
Election of Remedies for Employees Covered By a Collective Bargaining Agreement.
5 U.S.C. § 7121(g), if you are covered by a collective bargaining agreement, you must choose one of three possible
avenues to pursue your prohibited personnel practice complaint: (a) a complaint to OSC; (b) an appeal to the Merit
Systems Protection Board (MSPB) (if the action is appealable under law or regulation), or (c ) a grievance under the
collective bargaining agreement. If you have already filed an appeal about your prohibited personnel practice
allegations with the MSPB, or a grievance about those allegations under the collective bargaining agreement, OSC
lacks jurisdiction over your complaint and cannot investigate it.
Deferral of Certain Complaints Involving Discrimination. Although OSC is authorized to investigate discrimination
based upon race, color, religion, sex, national origin, ag e, or handicapping condition, as well as reprisal for filing an
EEO complaint, OSC generally defers such allegations to agency procedures established under regulations issued by
the Equal Em ployment Opportunity Commission (EEOC). 5 C.F.R. § 1810.1. If you wish to report allegations of
discrimination based upon race, color, religion, sex, national origin, age, or handicapping condition, or reprisal for filing
an EEO comp laint, you sho uld contact yo ur agency’s EEO office immediately. Ther e are specific time limits for filing
such complaints. Filing a complaint with OSC will not relieve you of the obligation to file a complaint with the agency’s
EEO office within the time prescribed by EEOC regulations (at 29 C.F.R. Part 1614).
Note:

This deferral policy does not apply to discrimination claims outside the jurisdiction of the
EEOC, such as complaints alleging discrimination based upon marital status or political
affiliation.

Complaints Involving Veterans Rights. By law, complaints alleging denial of veterans’ preference requirements
must be filed with the Veterans Employment and Training Service (VETS) at the Department of Labor. 38 U.S.C.
§ 4301, et seq., and 5 U.S.C. § 3330a(a). Certain allegations of discrimination based on the past, current, or
future performance of military service (e.g., discrimination based on veteran or reservist status) may be filed
with OSC. Thus, you are encouraged to contact OSC’s Uniformed Services Employment and Reemployment
Rights Act (USERRA) Unit by e-mail at [email protected] or by telephone at 202-254-3600.

SEND COMPLETED COMPLAINT FORMS TO OSC –
By Mail:

By Fax:
Electronically:

Complaints Examining Unit
Office of Special Counsel
1730 M Street, N.W. (Suite 218)
Washington, DC 20036-4505
(202) 254-3711
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 MAKE FOR COPIES OF MATERIALS THAT YOU PROVIDED TO OSC.
IF YOU ARE FILING AN ALLEGATION OF REPRISAL FOR WHISTLEBLOWING,
PLEASE SEE PART 2 OF THE COMPLAINT FORM, AT PAGES 4-5, FOR OTHER RECORDKEEPING
CONSIDERATIONS.

U.S. OFFICE OF SPECIAL COUNSEL

(202) 254-3600 / (202) 254-3670 / (800) 872-9855

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE
OR
OTHER PROHIBITED ACTIVITY
(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 at page 12.)

PART 1: PROHIBITED PERSONNEL PRACTICES / OTHER PROHIBITED ACTIVITY (GENERAL)
1.

Name of person seeking OSC action ("Complainant"):

Mr. (

)

Ms. (

)

Mrs. (

)

Miss (

)

__________________________________________________________________________________________________
For USERRA complaints only – please provide the last digit only of your Social Security Number (SSN):_____
(needed to determine jurisdiction under § 204(c)(2) of Public Law No. 108-454.)
2.

Position, title, series, and grade: _____________________________________________________________________
_______________________________________________________________________________________________

3. Agency name:
4.

___________________________________________________________________________________

Agency address: _________________________________________________________________________________

__________________________________________________________________________________________________
5.

Home or mailing address: __________________________________________________________________________

6.

_______________________________________________________________________________________________
Contact information:
Telephone number(s):
(
) ___________________ (Home)

7.

(

) ___________________ (Office) Ext. ______

Fax number:

(

) ___________________

E-mail address:

________________________________________________

If you are filing this complaint as a legal or other representative of the Complainant, please supply the following
information:
Name and title of filer:

Mr. (

)

Ms. (

)

Mrs. (

)

Miss (

)

___________________________________________________________________________________________
Address:____________________________________________________________________________________
___________________________________________________________________________________________
Telephone number(s):

(

) ___________________ (home)

(

) ___________________ (office) Ext. ______

Fax number:

(

) ___________________

E-mail address:

_____________________________________________________________________

8. Are you (or is the Complainant, if you are filing as a representative) covered by a collective bargaining agreementC
(Check one)
( ) Yes
( ) No
( ) I don't know
9. How did you first become aware that you could file a complaint with OSC?
(

) OSC Web site
( ) news story

(

) other (please describe):

(

) OSC speaker
( ) OSC brochure
(
( ) agency personnel office
( ) union

) OSC poster
( ) co-worker

___________________________________________________________
Date (approximate): ___________________________________________

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 2 of 12

10.

What is the employment status of the person affected by the suspected prohibited personnel practice or
other prohibited activity? (Check all applicable items – more than one item may apply.)
a. (

)

Applicant for Federal employment

b. (

)

Competitive Service
( ) temporary appointment
( ) term appointment

(
(

) career or career-conditional appointment
) probationary employee

c.

(

)

Excepted Service
( ) Schedule A
( ) Schedule B
( ) Schedule C
( ) National Guard Technician
( ) nonappropriated fund

(
(
(
(
(

)
)
)
)
)

d. (

)

Senior Executive Service (SES), Supergrade, or Executive Level
( ) Executive Level V or above (career) fund
( ) career SES
( ) noncareer SES
( ) Executive Level V or above (noncareer)
( ) career GS-16, 17, or 18
( ) Presidential appointee (Senate-confirmed)
( ) noncareer GS-16, 17, or 18

e. (

)

Other
( ) civil service annuitant
( ) former civil service employee
( ) competitive service
( ) excepted service

11. What other action(s) , if any, have you taken,
procedure? (Check all that apply.)
(
(
(

)
)
)

(

)

(
(
(
(
(
(

)
)
)
)
)
)

(
(

)
)

(

)

(
(

)
)

(

)

(
(
(
(

)
)
)
)

Postal Service
Tennessee Valley Authority
VA Dept. of Medicine and Surgery
Veterans Readjustment Act (VRA)
other (specify): __________________________

military officer or enlisted person
contract employee
other (specify): __________________________
unknown

to appeal, grieve, or report this matter under any other

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

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 3 of 12

12. What official is responsible for the violation(s) that you are reporting, and what is his/her employment
status? (See question 10 for appropriate description of employment status. If space is needed to identify
more than one official, use Continuation Sheet at page 12.)
Name: _______________________________________________________________________________
Position/Title: __________________________________________________________________________
Employment status: ________________________ _____________________________________________
13. What are the actions or events that you are reporting to OSC? ( To the extent known, specifically list: (a) any
suspected prohibited personnel practices or other prohibited activity, other than reprisal for whistleblowing;
and (b) any personnel actions involved.) IF YOU ARE ALLEGING REPRISAL FOR WHISTLEBLOWING,
SKIP TO PART 2 ON THE NEXT PAGE.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
14. Provide details of the ac tions or events shown in your response to question 13. (Be as specific as possible
about dates, locations, and the identities and positions of all persons mentioned. In particular, identify actual
and potential witnesses, giving work locations and telephone numbers when possible. Also, attach any
pertinent documents that you may have. Please provide, if possible, a copy of the notification of the
agency's proposal and/or decision about the personnel action(s) covered by your request for OSC action. If
more space is needed, use Continuation Sheet at page 12.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
15. What action would you like OSC to take in this matter (that is, what remedy are you asking for)?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 4 of 12

PART 2: REPRISAL FOR WHISTLEBLOWING

This part of the form is solely for use by persons alleging reprisal for whistleblowing
(that is, persons who believe that personnel actions were taken, not taken, or
threatened because of a whistleblower disclosure). Please read the introductory
material before answering the questions that follow. If more space is needed, use the
continuation sheet at page 12.
Complainants not alleging reprisal for whistleblowing should proceed to Part 3
(“Consent to Certain Disclosures of Information”), at page 9.

Reprisal for Whistleblowing Allegations
As a general rule, it is a prohibited personnel practice to take or fail to take, or threaten to take or fail to take, a
personnel action because of a protected disclosure of certain types of information by a Federal employee,
former employee, or applicant for Federal employment. 5 U.S.C. § 2302(b)(8).
Legal Elements of a Violation
By law, certain elements must be present before OSC can establish that a violation of law has occurred. Two of
the required elements that must be established are: (1) that a whistleblower disclosure was made; and (2) that
an agency took, failed to take, or threatened to take or fail to take a personnel action because of the
whistleblower disclosure. Your description of these elements will help OSC's investigation of your allegation(s).
Protected Disclosures
A disclosure of information is a protected whistleblower disclosure if a Federal employee, former employee, or
applicant for Federal employment discloses informati on which he or she reasonably believes evidences: (a) a
violation of any law, rule, or regulation; (b) gross mismanagement; (c) a gross waste of funds; (d) abuse of
authority; or (e) a substantial and specific danger to public health or safety.
Covered Personnel Actions
The law prohibiting reprisal for whistleblowing requires proof that one or more of the following personnel actions
occurred, or failed to occur, because of a legally protected disclosure:
(1)

an appointment;

(2)

a promotion;

(3)

an action under 5 U.S.C. chapter 75 or other disciplinary or corrective action;

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 5 of 12

(4)

a detail, transfer, or reassignment;

(5)

a reinstatement;

(6)

a restoration;

(7)

a reemployment;

(8)

a decision about pay, benefits, or awards, concerning education or training if the education or training
may reasonably be expected to lead to an appointment, promotion, performance evaluation, or other
action described in 5 U.S.C. § 2302(a)(2);

(9)

a performance evaluation under 5 U.S.C. chapter 43;

(10) a decision to order psychiatric testing or examination; or
(11) any other significant change in duties, responsibilities, or working conditions.
Reporting Your Allegation(s)
In the section that starts below (pages 6-8), provide the information requested about all disclosures that you
believe led to reprisal by the agency involved. If more space is needed, use extra copies of pages 6-8, or the
Continuation Sheet at page 12.

If any of the disclosures were in writing, please provide a copy of those

disclosure(s) with your complaint.
IT IS IMPORTANT THAT YOU LIST ALL DISCLOSURES AND PERSONNEL ACTIONS INVOLVED IN YOUR
COMPLAINT. This is because: (1) failure to list any disclosure or personnel action may delay the processing of
your complaint by OSC; and (2) a comprehensive listing will avoid disputes in any later Individual Right of Action
(IRA) appeal that you may file with the Merit Systems Protection Board (MSPB) about its jurisdiction to hear the
case.
Additional allegations of reprisal for whistleblowing may be added to this complaint while it is pending at OSC.
Submission of any such additional allegations to OSC _in writing will help you if you decide to file any later IRA
appeal with the MSPB. Form OSC -11a is available for that purpose at OSC’s web site, under “Forms.”
Appeal to the MSPB
If OSC fails to complete its review of your whistleblower reprisal allegation within 120 days after it receives your
complaint, or if it closes your complaint at any time without seeking corrective action on your behalf, you have
the right to file an IRA appeal with the MSPB. 5 U.S.C. § 1214(a)(3).
Recordkeeping
To establish its jurisdiction over any later IRA appeal that you may file, the MSPB will require you to show that
the appeal relates to the same whistleblower disclosure(s) and personnel action(s) involved in your complaint to
OSC. A copy of the whistleblower reprisal allegations in your complaint, any supporting documentation about
those allegations that you sent with the complaint, and any additional allegation of reprisal that you submitted in
writing to OSC while the complainant was pending , will serve as proof in any IRA of the disclosure(s) and
personnel action(s) involved in your OSC complaint. IT IS IMPORTANT, THEREFORE, THAT YOU MAKE AND
KEEP COPIES OF ALL THESE DOCUMENTS FOR YOUR RECORDS .

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 6 of 12

MUST BE COMPLETED FOR ALL DISCLOSURES REPORTED IN THIS COMPLAINT
A. WHAT INFORMATION WAS DISCLOSED?
(DESCRIBE WHISTLEBLOWER DISCLOSURE)
1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

2. TO WHOM (NAME AND TITLE) WAS THE DISCLOSURE MADE?

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that
apply):
(
) VIOLATION OF LAW, RULE, OR REGULATION
(
) GROSS MISMANAGEMENT
(
) GROSS WASTE OF FUNDS
(
) ABUSE OF AUTHORITY
(
) SUBSTANTIAL AND SPECIFIC DANGER TO
PUBLIC HEALTH OR SAFETY
(
) NONE OF THE ABOVE
4. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR,
OR WAS THREATENED BECAUSE OF THE DISCLOSURE? (List
all applicable personnel action numbers from pages 4-5.)

5. WHEN DID PERSONNEL ACTION(S) OR THREAT(S) OCCUR?
(MO/DA/YR)

B. WHAT INFORMATION WAS DISCLOSED?
(DESCRIBE NEXT WHISTLEBLOWER DISCLOSURE)
1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

2. TO WHOM (NAME AND TITLE) WAS THE DISCLOSURE MADE?

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that
apply):
(
) VIOLATION OF LAW, RULE, OR REGULATION
(
) GROSS MISMANAGEMENT
(
) GROSS WASTE OF FUNDS
(
) ABUSE OF AUTHORITY
(
) SUBSTANTIAL AND SPECIFIC DANGER TO
PUBLIC HEALTH OR SAFETY
(
) NONE OF THE ABOVE
4. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR,
OR WAS THREATENED BECAUSE OF THE DISCLOSURE? (List
all applicable personnel action numbers from pages 4-5.)

5. WHEN DID PERSONNEL ACTION(S) OR THREAT(S) OCCUR?
(MO/DA/YR)

KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 7 of 12

MUST BE COMPLETED FOR ALL DISCLOSURES REPORTED IN THIS COMPLAINT
C. WHAT INFORMATION WAS DISCLOSED?
(DESCRIBE NEXT WHISTLEBLOWER DISCLOSURE)
1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

2. TO WHOM (NAME AND TITLE) WAS THE DISCLOSURE MADE?

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that
apply):
(
) VIOLATION OF LAW, RULE, OR REGULATION
(
) GROSS MISMANAGEMENT
(
) GROSS WASTE OF FUNDS
(
) ABUSE OF AUTHORITY
(
) SUBSTANTIAL AND SPECIFIC DANGER TO
PUBLIC HEALTH OR SAFETY
(
) NONE OF THE ABOVE
4. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR,
OR WAS THREATENED BECAUSE OF THE DISCLOSURE? (List
all applicable personnel action numbers from pages 4-5.)

5. WHEN DID PERSONNEL ACTION(S) OR THREAT(S) OCCUR?
(MO/DA/YR)

D. WHAT INFORMATION WAS DISCLOSED?
(DESCRIBE NEXT WHISTLEBLOWER DISCLOSURE)
1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

2. TO WHOM (NAME AND TITLE) WAS THE DISCLOSURE MADE?

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that
apply):
(
) VIOLATION OF LAW, RULE, OR REGULATION
(
) GROSS MISMANAGEMENT
(
) GROSS WASTE OF FUNDS
(
) ABUSE OF AUTHORITY
(
) SUBSTANTIAL AND SPECIFIC DANGER TO
PUBLIC HEALTH OR SAFETY
(
) NONE OF THE ABOVE
4. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR,
OR WAS THREATENED BECAUSE OF THE DISCLOSURE?
(List all applicable personnel action numbers from pages 4-5.)

5. WHEN DID PERSONNEL ACTION(S) OR THREAT(S) OCCUR?
(MO/DA/YR)

KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 8 of 12

MUST BE COMPLETED FOR ALL DISCLOSURES REPORTED IN THIS COMPLAINT
3.

If you are not the person who actually made a disclosure described in boxes A, B, C, or D above, please
check below to specify the disclosure involved, and provide the name, address, and telephone number of
the person who made the disclosure, if known. (If space is needed to identify more than one person, use
Continuation Sheet at page 12.)
Disclosure:

A (

)

B (

)

C (

)

D (

)

Name:

____________________________________________________________________________

Address:

____________________________________________________________________________
____________________________________________________________________________

Telephone number: (
4.

) ___________________ Ext. ______

Explain why you believe that the personnel action(s) listed above occurred because of the disclosure(s) that
you described. (Be as specific as possible about any dates, locations, names, and positions of all persons
mentioned in your explanation. In particular, identify actual and potential witnesses, giving work locations
and telephone numbers, if known. Attach a copy of any documents that support your statements. Please
provide, if possible, a copy of the notification of the agency's proposal and/or decision about the personnel
action(s) covered by your complaint. If more space is needed, use Continuation Sheet at page 12.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

5.

What action would you like OSC to take in this matter (that is, what remedy are you asking for)?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 9 of 12

PART 3: CONSENT TO CERTAIN DISCLOSURES OF INFORMATION

OSC asks everyone who files a complaint alleging a possible prohibited personnel practice or other prohibited
activi ty 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 t he 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 opport unity 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). Info rmation 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 agency involved in my complaint. I agree to allow OSC to disclose
my identity as the complainant, and information from or about me, to the agency if OSC decides that such
disclosure is needed to investigate the allegation(s) in my complaint (for example, to request information from
the agency, or seek a possible resolution through mediation or corrective action). 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 agency involved in my complaint, but I do not agree to allow OSC to
disclose my identity as the complainant to that agency. 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 (for example, to request information from the agency, or
seek a possible resolution through mediation or corrective action). I understand that in some circumstances (for
example, if I am complaining about my failure to receive a promotion), OSC could not maintain my anonymity
while communicating with the agency involved about a specific personnel action. 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 agency involved in my complaint. I understand that if OSC
decides that it cannot investigate the allegation(s) in my complaint without communicating with that agency, 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 PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 10 of 12

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.
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Signature

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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 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 disc iplinary 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 inf ormation 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;

9.

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

Privacy Act and Routine Uses. Limited disclosure of information from OSC files is needed to fulfill OSC's investigative,
prosecutorial, and related responsibilities. OSC has described 27 routine uses (“a” through “aa”) for information in its
files in the Federal Register (F.R.), at 77 F.R. 24242 (April 23, 2012). A copy of the routine uses is available from OSC
upon request. A summary of the routine uses appears below. 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 or whistleblower
permitting the disclosure.
OSC may disclose information from its files in the following circumstances to:
a. disclose that an allegation of prohibited personnel practices or other prohibited activity has been filed;
b. 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;
c. disclose information about allegations or complaints of discrimination to entities concerned with enforcement of
antidiscrimination laws;
d. the Merit Systems Protection Board (MSPB) or the President, when seeking disciplinary action;
e. 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;
f. disclose information to Congress in OSC's annual report;
g. disclose information to third parties as needed to conduct an investigation; resolve an allegation; or to give notice of
the status or outcome of an investigation; and to an agency, Office of Inspector General (OIG), complainant
(whistleblower), the President, Congressional Committees, or the National Security Advisor regarding disclosures under
5 U.S.C. 1213; or to give notice of the status or outcome of a review;
h. disclose information as needed to obtain information about hiring or retention of an employee; issuance of a security
clearance; classification of a job; conduct of a security or suitability investigation; award of a contract; or issuance of a
license, grant, or other benefit;
i. the Office of Management and Budget (OMB) for certain legislative coordination and clearance
purposes;
j. provide information from an individual's record to a congressional office acting pursuant to the
individual's request;
k. furnish information to the National Archives and Records Administration for records management
purposes;
l. produce summary statistics and workforce or other studies;
m. provide information to the Department of Justice (DOJ) as needed for certain litigation purposes;
n. provide information to courts or adjudicative bodies as needed for certain litigation purposes;
o. disclose information to the MSPB as needed in special studies authorized by law;
p. coordinate with an agency's OIG or comparable entity, to facilitate the coordination and conduct of investigations and
review of allegations, including notification of the disposition of matters referred to OSC by that office;
q. 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);
r. the Department of Labor and others as needed to implement the Uniformed Services Employment
and Reemployment Rights Act of 1994 (USERRA), as amended, including demonstration projects, and the Veterans’
Employment Opportunities Act of 1998, or disclose information to the Department of Defense, Employer Support of the
Guard and Reserve for mediation;

s. disclose records, when OSC has agreed to represent a USERRA complainant, from the corresponding investigative
file to the relevant litigation file, and from the litigation file to the complainant;
t. disclose information to agency contractors, or other non-OSC employees performing or working on a contract,
service, or other activity as needed to accomplish an agency function;
u. make lists and reports available to the public pursuant to 5 U.S.C. 1219;
v. disclose information as needed to appropriate agencies, entities, and persons in the event of a confirmed or
suspected data breach to respond to and prevent, minimize, or remedy harm;
w. disclose information to appropriate federal entities with subject matter expertise as needed to obtain advice on any
authorities, programs, or functions associated with records in this system;
x. disclose information to appropriate law enforcement entities where OSC becomes aware of a violation or potential
violation of civil or criminal law or regulation; and to OPM and OMB pursuant to 5 U.S.C. 1214;
y. disclose information, when necessary, to the Integrity Committee established under the Inspector General Act, and
under section 7(b) of Public Law 110-409;
z. disclose information to the DOJ and/or the Federal Bureau of Investigation, as required, for inclusion in the National
Instant Criminal Background Check System; and
aa. disclose information to another Federal entity, as needed, under the Freedom of Information Act or the Privacy Act.

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: (a) allegations of prohibited personnel practices, to the extent necessary to determine whether there are
reasonable grounds to believe that a prohibited personnel practice has occurred, exists, or is to be taken (5 U.S.C. § 1214);
and (b) other allegations of prohibited activity (5 U.S.C. § 1216). 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 and corrective or
disciplinary action is warranted. The reporting burden for this collection of information is estimated to be an average of one
hour and 15 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. Use of this form to file a complaint alleging a prohibited personnel practice or
other prohibited activity is required; use of this to file a complaint alleging only a Hatch Act violation is not required. 5 C.F.R. §
1800.1(d), as amended. As stated in Part 3 of this form, complainants may request that OSC maintain their name, and
information provided by them, in confidence.

Part No. Item/Question No.
Response Continuation

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 12 of 12

CONTINUATION SHEET
Part No.

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Response Continuation

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KEEP A COPY OF THIS PAGE FOR YOUR RECORDS
(ESPECIALLY IF YOU ARE ALLEGING REPRISAL FOR WHISTLEBLOWING)