OSC Form 11 Complaint of Possible Prohibited Personnel Practice

U.S. OFFICE OF SPECIAL COUNSEL
Form OSC-11 (2/28/14)

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 important, 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).

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 complaints (except a complaint
alleging only a Hatch Act violation) that are not submitted on this form. OSC will return the material received, with
a blank complaint form 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
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Election of Remedies for Employees Covered By a Collective Bargaining Agreement. Pursuant to 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, age, 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 Employment 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 complaint, you should contact your agency’s EEO office
immediately. There 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 DOCUMENTION, 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 FROM, AT PAGES 4-5, FOR OTHER RECORDKEEPING
CONSIDERATIONS.

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

U.S. OFFICE OF SPECIAL COUNSEL

PART 1: PROHIBITED PERSONNEL PRACTICES 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)

(

)

(Office) Ext.

(

)

Fax number:
E-mail address:

7. 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): (

)

(

)

Fax number: (

)

(Home)
(Office) Ext.

E-mail address:
8. Are you (or is the Complainant, if you are filing as a representative) covered by a collective bargaining agreement? (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

(

) OSC Speaker

(

) OSC Brochure

(

) OSC Poster

(

) NewsStory

(

) Agency Personnel Office

(

) Union

(

) Co-worker

(

) Other (please describe):
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
(
(

c.

(

) temporary appointment
) term appointment

) Excepted Service
(
(
(
(
(

d.

(

) Schedule A
) Schedule B
) Schedule C
) National Guard Technician
) Non-appropriated Fund

(
(
(
(
(

) Postal Service
) TennesseeValley Authority
) VA Dept. of Medicine and Surgery
) Veterans Readjustment Act (VRA)
) Other (Specify)

) SeniorExecutive Service (SES), Supergrade, or Executive Level
(
(
(
(

e. (

)
)
)
)

career SES
noncareer SES
career GS-16, 17, or 18
noncareer GS-16, 17, or 18

(
(
(

) Executive Level V or above (career) fund
) Executive Level V or above (noncareer)
) Presidentia lappointee (Senate-confirmed)

(
(
(
(

)
)
)
)

) Other
(
(
(
(

) civil service annuitant
) formercivil service employee
) competitive service
) excepted service

militaryofficer or enlisted person
contract employee
other (specify):
unknown

11. 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 Office of Personnel Management
Unfair labor practice (ULP) complaint filed with 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:

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
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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 actions 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
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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 legal 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 information 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

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

(4)
(5)
(6)
(7)
(8)

a
a
a
a
a

detail, transfer, or reassignment;
reinstatement;
restoration;
reemployment;
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)

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
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 Merit Systems Protection Board (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 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 complaint 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 DOCUMENT FOR YOUR RECORDS.

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
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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

(

PUBLICHEALTH OR SAFETY
) NONE OF THE ABOVE

4. WHAT PERSONNEL ACTION(S) 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
(

PUBLICHEALTH OR SAFETY
) NONE OF THE ABOVE

4. WHAT PERSONNEL ACTION(S) 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 COMPLETEDFOR 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
PUBLICHEALTH OR SAFETY
) NONE OF THE ABOVE

(

4. WHAT PERSONNEL ACTION(S) OCCURRED, FAILED TO OCCUR,
OR WAS THREATENED BECAUSE OF THE DISCLOSURE?

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

(

PUBLICHEALTH OR SAFETY
) NONE OF THE ABOVE

4. WHAT PERSONNEL ACTION(S) 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
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MUST BE COMPLETED FOR ALL DISCLOSURES INCLUDED IN THIS COMPLAINT

3. If you are not the person who actually made a disclosure described in boxes A, B, C, 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:

B(

)

C(

)

D(

)

Name:
Address:

Telephone number:

(

)

Ext.

4. 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, continue on 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
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PART 3: CONSENT TO CERTAIN DISCLOSURES OF INFORMATION
OSC asks everyone who files a complaint alleging a possible prohibited personnel practice or other prohibited activity 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)

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

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
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PART 4: CERTIFICATION AND SIGNATURE

________________________________________________________
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.

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

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY
Page 11 of 12

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: (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.

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE / OTHER PROHIBITED ACTIVITY
Page 12 of 12

CONTINUATION SHEET
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