Form 14 Electronic Submission of Allegations and Disclosures

USOSC Form 14 Full Form 071219.pdf

FORM 14: ELECTRONIC SUBMISSION OF ALLEGATIONS AND DISCLOSURES

Form 14 Electronic Submission of Allegations and Disclosures

OMB: 3255-0005

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3255-0005 can be found here:

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U.S. Office of Special Counsel
Complaint & Disclosure Form
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Complaint Type

The U.S. Office of Special Counsel (OSC) is an independent federal investigative and
prosecutorial agency. Our basic authorities come from four federal statutes: the Civil
Service Reform Act, the Whistleblower Protection Act, the Hatch Act, and the Uniformed
Services Employment & Reemployment Rights Act (USERRA). For more information on
OSC, please visit our website at www.osc.gov.
OSC requires that you use this form in order to submit a complaint alleging a prohibited
personnel practice or other prohibited activity within OSC's jurisdiction. OSC
encourages, but does not require, you to use this form to submit a complaint alleging a
Hatch Act violation or to submit a disclosure of information alleging agency wrongdoing.
OSC cannot process incomplete forms lacking necessary information.
Please use this form to file a complaint or disclosure by selecting each box that
applies below:
1. I want to file a complaint about a prohibited personnel practice, such as
retaliation, discrimination, or illegal hiring decisions.
2. I want to make a disclosure about gross mismanagement or waste, a violation
of law, rule or regulation, abuse of authority, a danger(s) to public health or
safety, or censorship related to scientific research.
Note: Do NOT select this box to report prohibited personnel practices, such as
retaliation, discrimination, or illegal hiring decisions. If you are filing to correct a
specific employment action, consider selecting 1, above. Do NOT select this
box to report a Hatch Act violation. If you are filing to report a Hatch Act
violation, select 3, below.
3. I want to file a complaint about improper political activity (under the Hatch Act).
I want to file a USERRA complaint about discrimination or reemployment as a member
of the uniformed services.
Note: If you click the link above, you will be immediately redirected to the website of
the Department of Labor to complete a USERRA complaint form.
Next

OSC Form-14

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

Navigation Bar
Add / Delete a Complaint
Improper Political Activities
(Hatch Act)
About Filing a Complaint
Biographical Information
Information about Subject
Alleged Violation
Other Actions
Attachments

PART 1: IMPORTANT INFORMATION ABOUT FILING A COMPLAINT
INSTRUCTIONS FOR FILING A HATCH ACT COMPLAINT WITH THE U.S. OFFICE
OF SPECIAL COUNSEL (OSC)
This form should be used to file complaints alleging violations of the Hatch Act. In
order for us to best understand your allegations, we encourage you to fill in all the
fields that you can. However, only those fields marked with an asterisk are required.
If you fail to fill in a required field, your complaint cannot be processed. When
providing information, please be as specific as you can, provide as much detail as
possible, and attach/enclose all supporting documentation with your complaint filing.
Prior to submitting your complaint to OSC, we recommend you review the information
located on our website . If you have any questions about this form, you may phone
the Hatch Act Hotline at (202) 804-7002.

Consent
Certification

PART 2: BIOGRAPHICAL INFORMATION

Submission

* Denotes Required Fields
1. Complainant Information:
Title
First Name

Middle Initial

Last Name
2. Contact Information:
Address Location

Domestic

International

Address Line 1
Address Line 2
City

State

Zip Code
Cell Phone Number
Office Phone Number

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

home phone

cell phone

office phone

Please do not contact me on my office phone
International Address

OSC Form-14
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

Navigation Bar
Add / Delete a Complaint
Improper Political Activities
(Hatch Act)

Cell Phone Number
Office Phone Number

Ext.

Home Phone Number

About Filing a Complaint

Email Address

Biographical Information

Preferred means of contact:

Information about Subject

Alleged Violation

Please do not contact me on my office phone

Other Actions

home phone

3. Do you have representation?

Attachments

Title

Consent

First Name

cell phone

Yes

office phone

Middle Initial

Certification

Last Name

Submission

Address Location

Domestic

International

Address Line 1
Address Line 2
City

State

Zip Code
Cell Phone Number
Office Phone Number

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

home phone

cell phone

office phone

Please do not contact me on my office phone
International Address
Cell Phone Number
Office Phone Number

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

OSC Form-14
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM
Page # of ##

home phone

cell phone

office phone

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

Navigation Bar
Add / Delete a Complaint
Improper Political Activities
(Hatch Act)
About Filing a Complaint

4. Are you referring this complaint on behalf of a government agency?
Yes
No
Agency:
Your Position Title:

Biographical Information

PART 3: INFORMATION ABOUT THE INDIVIDUAL WHO
ALLEGEDLY VIOLATED THE HATCH ACT (Subject)

Information about Subject
Alleged Violation
Other Actions
Attachments
Consent
Certification
Submission

* Denotes Required Fields
Subject’s Employment Status:*
Federal government employee
State or Local government employee
Private, Nonprofit organization employee
Title:
Subject’s First Name:*

Subject’s Middle Initial:

Subject’s Last Name:*
Employer:*
Department name:*
Agency:*
Position Title:
Subject’s Address*

Domestic

International

Address Line 1*
Address Line 2
City*

State*

Zip Code*
Office Telephone:

Ext.

Home Telephone:

Other Telephone:

Email Address:
International Address*

OSC Form-14
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

Navigation Bar
Add / Delete a Complaint
Improper Political Activities
(Hatch Act)
About Filing a Complaint
Biographical Information
Information about Subject
Alleged Violation
Other Actions

Office Telephone:

Ext.

Home Telephone:

Other Telephone:

Email Address:
Does the Subject have knowledge of the Hatch Act?:*
Yes

Unsure

If yes, please explain why you believe the Subject knows about the Hatch Act (for
example: agency training, agency distribution of brochures, flyers, e-mails, prior
contact with OSC):

Attachments
Consent

SUBJECT’S SUPERVISOR’S INFORMATION

Certification
Submission

Subject’s Supervisor’s First Name:
Subject’s Supervisor’s Last Name:
Subject’s Supervisor’s Middle Initial:
Subject’s Supervisor’s Title:
Office Telephone:

Ext.

Other Telephone:

Fax:

Email Address:

FEDERAL FUNDING INFORMATION
1. Does the Subject’s employer receive any federal funds?:

Yes

2. Is the Subject’s salary paid entirely with federal funds?:

Yes

3. Does the Subject perform any duties in connection with a
federally funded activity?:

Yes

If you answered “No” to both Questions 2 and 3, OSC does not have jurisdiction over
your complaint. If you answered “Yes” to either Question 2 or 3, please provide the
information requested below in as much detail as possible.
a. Please describe the duties the Subject performs in connection with the federally
funded activity and attach/enclose any supporting documentation with your
complaint filing:

OSC Form-14
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

Navigation Bar
Add / Delete a Complaint
Improper Political Activities
(Hatch Act)
About Filing a Complaint
Biographical Information
Information about Subject

b. Please describe the federal funding with which the Subject has a connection and
attach/enclose any supporting documentation with your complaint filing:
The following questions are provided to assist you in describing the nature and
source of the federal funds at issue:
-What is the name of the federal agency that awarded, distributed, or administered
the funds in question?
-What is the name and/or number of the federal grant or loan?
-What is the purpose of the federal funding? (i.e., how are the funds used?)

Alleged Violation
Other Actions
Attachments
Consent

c. Please provide the name and contact information for an individual who has
knowledge about the federal fund(s) at issue and whom OSC may contact:
Name:

Certification

Agency :

Submission

Position Title:
Office Telephone:

Fax:

Email Address:

PART 4: ALLEGED VIOLATION
* Denotes Required Fields
1. For complaints involving a Subject employed by the federal government, which of the
following actions are you alleging?*
Using one’s official authority or influence for the purpose of interfering with or
affecting the result of an election.
Soliciting, accepting, or receiving political contributions.
Being a candidate in a partisan election.
Soliciting or discouraging the participation in political activity of any person who
has business before their employing agency.
Engaging in political activity while on duty, in any room or building occupied in the
discharge of official duties, while wearing a uniform or official insignia, or while
using a vehicle owned or leased by the United States government.
Taking an active part in political management or political campaigns (This
prohibition applies only to further restricted employees. A list of such employees
can be found here or at 5 U.S.C. § 7323(b)).

OSC Form-14
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

1. For complaints involving a Subject employed by a state, local, D.C., or nonprofit
agency, which of the following actions are you alleging?*
Using one’s official authority or influence for the purpose of interfering with or
affecting the result of an election.
Coercing, attempting to coerce, commanding, or advising a state or local officer or
employee to pay, lend, or contribute anything of value to a party, committee,
organization, agency, or person for political purposes.
Being a candidate in a partisan election.
2. Please provide a detailed description of the alleged violation(s) and attach/enclose
any supporting documentation with your complaint filing. To process your complaint,
you must provide as much detailed information as possible. Without sufficient
information, we may be unable to investigate your allegation(s).*
A detailed description should include:
a. What the Subject did that allegedly violated the Hatch Act;
b. Where the alleged violation(s) occurred;
c. When the alleged violation(s) took place; and
d. Who else has knowledge that the alleged violation(s) occurred and their relationship
to the Subject.
For instance, a complaint alleging that the Subject is a candidate in a partisan election
for public office should include: the name of the office which the Subject seeks (for
example, Council of the District of Columbia or Mayor of Baltimore, Maryland); the date
of the election; the type of election (primary, special, or general); and how the election
is partisan (for example: candidates are running with political party affiliation). Please
note that the Hatch Act does not prohibit candidacy in a nonpartisan election.

PART 5: ATTACHMENTS TO YOUR COMPLAINT
I would like to attach documents to my complaint.

ATTACH

Please attach documents and/or evidence that support your allegations. Note that
the space available for attachments is limited, and you will have an opportunity to
make additional submissions at a later date.
To see the attachments that have been successfully added to your form, click on
the paperclip icon
in the dark gray panel on the far left side of your screen.
Please note that, if you print a copy of your form, the attachments will not print with
it. However, any documents that appear in the paperclip panel
will be
transmitted to OSC.

OSC Form-14
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

Navigation Bar
Add / Delete a Complaint
Improper Political Activities
(Hatch Act)
About Filing a Complaint
Biographical Information

PART 6: OTHER ACTIONS YOU ARE TAKING
Please indicate in this section if you have reported your matter through other agencies
or organizations. If so, please identify the agency or organization to which you reported
the matter and provide the current status. If you have received responses regarding
your matter, briefly summarize what results were communicated to you and provide
our office with copies of any correspondence.

Information about Subject
Alleged Violation
Other Actions
Attachments
Consent
Certification
Submission

PART 7: CONSENT TO DISCLOSURE OF INFORMATION
* Denotes Required Fields
Do you consent to the disclosure of your identity to others outside OSC if it becomes
necessary in taking further action on this matter?*
I consent to the disclosure of my identity on a need-to-know basis.
I do not consent to the disclosure of my identity. (I understand my lack of consent
may prevent OSC from taking further action on my complaint. Even if I do not
consent, OSC may disclose my identity if required by law.)
Next

OSC Form-14
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

PART 1: IMPORTANT INFORMATION ABOUT FILING A COMPLAINT
Required Complaint Form. Complaints alleging a prohibited personnel practice or a
prohibited activity must be submitted on this form, either by e-filing or by mail.
Information not submitted on or accompanied by this form may be returned by OSC to
the filer. The complaint will be considered filed on the date on which OSC receives the
completed form. 5 C.F.R. § 1800.1, as amended.

Biographical Information

No OSC Jurisdiction. OSC cannot take any action on complaints filed by employees of
Your Complaint
• the FBI, CIA, DIA, NSA, National Geospatial-Intelligence Agency, ODNI, National
Reconnaissance Office or other intelligence agencies excluded from coverage by
Retaliation for
the President;
Whistleblowing
• the Government Accountability Office;
Retaliation for Protected
• the Postal Rate Commission; and
Activity
• the uniformed services of the United States (i.e., uniformed military employees).
Obstruct Competition
OSC does have jurisdiction over civilian employees of the armed forces.
Give Unauthorized
Limited OSC Jurisdiction. For employees of some federal agencies or entities, OSC’s
Preference
jurisdiction is limited to certain types of complaints, as follows –
Encourage Withdrawal from
• FAA employees only for allegations of retaliation for whistleblowing under
Competition
5 U.S.C. § 2302(b)(8) and most allegations of retaliation for engaging in protected
activities under 5 U.S.C. § 2302(b)(9).
Nepotism
• employees of government corporations listed at 31 U.S.C. § 9101 only for
Improper Political
allegations of retaliation for whistleblowing under 5 U.S.C. § 2302(b)(8) and most
Recommendation
allegations of retaliation for engaging in protected activities under
Violate Veterans’
5 U.S.C. § 2302 (b)(9).
Preference
• U.S. Postal Service employees only for allegations of nepotism.
Discrimination for
• TSA employees only for allegations of discrimination under § 2302(b)(1), retaliation
Non-Job-Related Conduct
for whistleblowing under 5 U.S.C. § 2302(b)(8), and most allegations of retaliation
Other Bases of
for engaging in protected activities under 5 U.S.C. § 2302(b)(9).
Discrimination
Election of Remedies. You may choose only one of three possible methods to pursue
Improper Personnel Actions your prohibited personnel practice complaint: (a) a complaint to OSC; (b) an appeal to
Non-Disclosure Agreement the Merit Systems Protection Board (MSPB) (if the action is appealable under law or
regulation); or (c) a grievance under a collective bargaining agreement. If you have
Improper Accessing of
already filed an appeal about your prohibited personnel practice allegations with the
Medical Records
MSPB, or a grievance about those allegations under the collective bargaining
agreement (if the action is grievable under the agreement), OSC may lack jurisdiction
Coerce Political Activity
over your complaint.5 U.S.C. § 7121(g).
Other
Attachments
Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference

Complaints Involving Discrimination.
• Race, Color, Religion, Sex, National Origin, Age, and Disability (or Handicapping
Condition): OSC is authorized to investigate discrimination based upon race, color,
religion, sex, national origin, age, or disability (or handicapping condition), as well
as retaliation related to EEO activity. 5 U.S.C. § 2302(b)(1). However, 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 on
these bases, 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 ).
• Marital Status and Political Affiliation: OSC is authorized to investigate
discrimination based on marital status or political affiliation. 5 U.S.C. § 2302(b)(1).
• Sexual Orientation and Gender Identity: OSC is authorized to investigate
discrimination based on sexual orientation and gender identity.
5 U.S.C. §§ 2302(b)(1) and (b)(10). EEOC also may have jurisdiction over
complaints of discrimination on these bases.

Encourage Withdrawal from Complaints Involving Veterans Rights. By law, all complaints alleging denial of
veterans’ preference requirements or USERRA must be filed with the Veterans
Competition
Employment and Training Service (VETS) at the Department of Labor (DOL).
Nepotism
38 U.S.C. § 4301, et seq., and 5 U.S.C. § 3330a(a).
Improper Political
Recommendation
Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination
Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar

PART 2: SELECT YOUR PPPs

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information

Please check ALL that apply (you MUST check one option). A customized series of
questions will appear following the “Biographical Information” section, below, based on
your selections. You can return to this part at any time prior to submitting your
complaint if you would like to add or remove allegations.
RETALIATION CLAIMS
Retaliation for Whistleblowing

Your Complaint

Retaliation for reporting a violation of law, rule, or regulation; gross mismanagement;
gross waste of funds; abuse of authority; a substantial and specific danger to public
health or safety; or censorship related to scientific research.
Retaliation for Protected Activity
Retaliation for filing a complaint or grievance; assisting another with a complaint or
grievance; cooperating with an OSC, OIG, or internal investigation; or refusing to
obey an illegal order.

Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference

ILLEGAL SELECTION PRACTICE CLAIMS

Nepotism

Obstruct Competition
Intentionally deceive or obstruct anyone from competing for federal employment.
Give Unauthorized Preference

Improper Political
Recommendation

Give an unauthorized preference or advantage, including defining the manner or
scope of competition, to improve or injure the employment prospects of any person.

Encourage Withdrawal from
Competition

Encourage Withdrawal from Competition
Influence or encourage anyone to withdraw from competition to improve or injure
the employment prospects of any person.
Nepotism
Involvement in the appointment, promotion, or advancement of a relative, or
advocacy on behalf of a relative.
Improper Political Recommendation
Request or consider a recommendation based on political connections or influence
rather than one based on personal knowledge of a person’s ability to perform a job.
Violate Veterans’ Preference
Take or fail to take, recommend, or approve a personnel action if doing so would
violate a veterans' preference requirement. This type of complaint must be filed
with the Department of Labor. Please click here to go to that site.

Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination
Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments

DISCRIMINATION CLAIMS

Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

Discrimination for Non-Job-Related Conduct
Discrimination for conduct that does not adversely affect job performance, including
claims of sexual orientation or gender identity discrimination.
Other Bases of Discrimination
OSC examines claims of discrimination based on marital status and political
affiliation. OSC does NOT ordinarily investigate claims of discrimination based on
race, color, religion, sex, national origin, age, and handicapping condition. These
claims are typically better filed with an agency’s EEO office.
OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Add / Delete a Complaint

OTHER CLAIMS

Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition

Improper Personnel Actions
Take or fail to take a personnel action if doing so would violate any law, rule, or
regulation implementing or directly concerning a merit system principle.
Non-Disclosure Agreement
Implement or enforce a non-disclosure agreement or policy that lacks notification of
whistleblower rights.
Improper Accessing of Medical Records
Accessing the medical records of another employee or applicant for employment
as a part of, or otherwise in furtherance of, the commission of a prohibited
personnel practice.
Coerce Political Activity
Coerce a person to engage in political activity, to include providing a political
contribution or service, or take action against a person for doing so.
Other
Please use this area to describe employment problems that do not fall into one of
the categories listed above.

Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination
Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar

PART 3: BIOGRAPHICAL INFORMATION

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)

* Denotes Required Fields
1. Complainant Information:

About Filing a Complaint

Title

Select your PPPs

First Name*

Biographical Information

Last Name*

Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition
Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination
Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records

Middle Initial

2. Contact Information:
Address Location*

Domestic

International

Address Line 1*
Address Line 2
City*

State*

Zip Code*
*At least ONE phone number OR email address is required.
Cell Phone Number
Office Phone Number

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

home phone

cell phone

Please do not contact me on my office phone
International Address*
*At least ONE phone number OR email address is required.
Cell Phone Number

Coerce Political Activity

Office Phone Number

Other

Home Phone Number

Attachments

Email Address

Consent

Preferred means of contact:
home phone

Ext.

Certification

Submission

Please do not contact me on my office phone

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

office phone

cell phone

office phone

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Add / Delete a Complaint

3. Do you have representation?*

Yes

Title

Prohibited Personnel
Practices (PPP)

First Name*

Middle Initial

About Filing a Complaint

Last Name*

Select your PPPs

Address Location*

Biographical Information

Address Line 1*

Your Complaint

Address Line 2

Domestic

International

City*

Retaliation for
Whistleblowing

State*

Zip Code*

Retaliation for Protected
Activity

*At least ONE phone number OR email address is required.

Obstruct Competition

Cell Phone Number

Give Unauthorized
Preference

Office Phone Number

Ext.

Home Phone Number

Encourage Withdrawal from
Competition

Email Address

Nepotism

Preferred means of contact:

Improper Political
Recommendation

home phone

cell phone

office phone

International Address*

Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct

*At least ONE phone number OR email address is required.

Other Bases of
Discrimination

Office Phone Number

Cell Phone Number
Home Phone Number

Improper Personnel Actions

Email Address

Non-Disclosure Agreement

Preferred means of contact:

Improper Accessing of
Medical Records
Coerce Political Activity
Other

Ext.

home phone

cell phone

office phone

4. Complainant’s employment status:*
Current Federal Employee

Attachments

Former Federal Employee

Consent

Applicant For Federal Employment

Certification

Non-Federal Employee (please specify below)

Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Add / Delete a Complaint

5. If current or former federal employee, please list most recent position title, series,
grade:
Title (for instance, Investigator)

Prohibited Personnel
Practices (PPP)

Series (for instance, GS-1810)

About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint

Grade (for instance, GS-9)
6. Please provide your dates of employment in this position.
7. Department name:*

Retaliation for
Whistleblowing

8. Agency name:*

Retaliation for Protected
Activity

9. Agency subcomponent:

Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition
Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference

10. Street Address:
11. City:*
12. State:*

Check here if agency address is international.

Country:*
13. Zip Code:
14.Are you covered by a collective bargaining agreement? (Check one.)
Yes
No
I don't know
15.Which of the following apply to your employment status? (Check all applicable items.)

Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination
Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

a. Competitive Service
Temporary appointment
Term appointment

Career or career-conditional appointment
Probationary employee

b. Excepted Service
Schedule A
National Guard Technician
Tennessee Valley Authority

Schedule B
Schedule C
Postal Service
Non-appropriated fund

Other (specify):
c. Senior Executive Service (SES) or Executive Level
Career SES
Executive Level V or above
Non-career SES
Presidential appointee (Senate-confirmed)
d. Other
Civil service annuitant
Former civil service employee
Unknown

Military officer or enlisted person
Contract employee
Other (specify):

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
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Add / Delete a Complaint

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

Prohibited Personnel
Practices (PPP)

None, or not applicable
Appeal with Merit Systems Protection Board (MSPB)

About Filing a Complaint

Grievance under collective bargaining agreement procedure Date:

Select your PPPs
Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity

Grievance filed under agency grievance procedure

Date:

Discrimination complaint filed with agency

Date:

USERRA claim with VETS (Department of Labor)

Date:

Appeal filed with Office of Personnel Management

Date:

Lawsuit filed in Federal Court

Date:

Court name:

Obstruct Competition
Give Unauthorized
Preference

Reported matter to agency Inspector General

Date:

Reported matter to member of Congress

Date:

Name of Senator or Representative:

Encourage Withdrawal from
Competition

Other (specify):

Nepotism
Improper Political
Recommendation

Date:

17. What action would you like for OSC to take if we find that a prohibited personnel
practice has occurred?

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
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PART 4: DETAILS OF YOUR COMPLAINT

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint

Retaliation for Whistleblowing
An agency official is prohibited from taking, failing to take, or threatening to
take or fail to take, a personnel action against an employee or applicant because the
individual made a disclosure of information that s/he reasonably believed evidenced
wrongdoing (i.e., a violation of any law, rule, or regulation; gross mismanagement; a
gross waste of funds; an abuse of authority; substantial and specific danger to public
health or safety; or censorship related to scientific research.) 5 U.S.C. § 2302(b)(8).
This is commonly referred to as a retaliation for whistleblowing claim.

Retaliation for
Whistleblowing

IMPORTANT INFORMATION ABOUT RETALIATION ALLEGATIONS

Retaliation for Protected
Activity

YOU SHOULD 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 help avoid disputes in any later Individual Right
of Action (IRA) appeal that you may file with the Merit Systems Protection Board
(MSPB).

Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition

You may add additional allegations of retaliation for whistleblowing to this
complaint while it is pending at OSC. Submission of any additional allegations to
OSC in writing will help you if you later decide to file an IRA appeal with the MSPB.

Nepotism
Improper Political
Recommendation

To establish its jurisdiction over an IRA appeal, the MSPB will require you to show
that your IRA appeal relates to the same disclosure(s) and personnel action(s)
raised in your complaint to OSC. The following documents will help meet this
requirement: a copy of the retaliation allegations in your complaint, any additional
allegation(s) of retaliation that you submitted to OSC in writing while the complaint
was pending, and any official correspondence you receive from OSC about your
complaint. IT IS IMPORTANT, THEREFORE, THAT YOU SAVE COPIES OF ALL
THESE DOCUMENTS FOR YOUR RECORDS.

Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination
Improper Personnel Actions

If OSC fails to complete its review of your whistleblower retaliation 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).

Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent

Certification
Submission

1. What did you disclose? If you made your disclosure in writing, please attach a copy
to your complaint before you submit it.

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
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2. When did you disclose it?

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)

3. To whom did you make your disclosure?

About Filing a Complaint
Select your PPPs

4. How did you learn of the information you disclosed?

Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition

5. When and how did agency officials learn about your disclosure?

6. What action did the agency take in response to your disclosure? (For example, did
the agency investigate or otherwise look into what you disclosed or was disciplinary
action taken against responsible parties?)

Give Unauthorized
Preference
Encourage Withdrawal from 7. What personnel action(s) do you believe was taken, not taken, or threatened
because of your disclosure?
Competition
Check all applicable:
Nepotism
Removal
Reinstatement
Improper Political
Suspension
Reassignment
Recommendation
Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination
Improper Personnel Actions
Non-Disclosure Agreement

Other Discipline

Harassment/Hostile Work Environment

VA Expedited Process

Psychiatric Examination

Gag Order

Performance Evaluation

Detail

Changes to Duties/Working Conditions

Promotion

Pay, Benefits, Training

Appointment

Other

Describe:

Improper Accessing of
Medical Records
Coerce Political Activity

8. When was the personnel action(s) taken? By whom?

Other
Attachments

9. What was the agency’s stated reason for taking the personnel action(s)?

Consent
Certification
Submission

10. What facts demonstrate that the personnel action(s) is retaliatory? (For example,
were comments made that suggest that agency officials were angry because of
your disclosure or did your relationships cool following your disclosure?)

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

11. Why do you believe agency officials would retaliate against you? (For example, did
agency officials suffer some adverse impact or embarrassment because of your
disclosure?)

12. Please provide the name, title, and position in your chain of command of the agency
official(s) involved in taking the personnel action(s) that you believe was retaliatory.

Biographical Information

First Name

Your Complaint

Last Name

Chain of Command
Title
(e.g., Deputy Director) (e.g., 1st level supervisor)
Del

Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition

Add Row

13. Were the agency officials involved in taking the personnel actions against you
accused of wrongdoing in your disclosures? If yes, which ones?

Give Unauthorized
Preference
Encourage Withdrawal from
Competition
Nepotism
Improper Political
Recommendation

Add Another Retaliation for
Whistleblowing Claim

Retaliation for Protected Activity

An agency official is prohibited from taking, failing to take, or threatening to
take or fail to take a personnel action against any employee or applicant for federal
Violate Veterans’
employment because of (A) the exercise of an appeal, complaint, or grievance right
Preference
granted by any law, rule or regulation; (B) testifying or otherwise lawfully assisting any
Discrimination for
individual in the exercise of any such right; (C) cooperating with or disclosing
Non-Job-Related Conduct information to the Inspector General (or any other component responsible for internal
investigation or review) of any agency, or the Special Counsel; or (D) refusing to obey
Other Bases of
an order that would require the individual to violate a law, rule, or regulation.
Discrimination
Improper Personnel Actions 5 U.S.C. § 2302(b)(9).
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar

IMPORTANT INFORMATION ABOUT RETALIATION ALLEGATIONS

Add / Delete a Complaint

YOU SHOULD LIST ALL PROTECTED ACTIVITIES AND PERSONNEL
ACTIONS INVOLVED IN YOUR COMPLAINT. This is because: (1) failure to list
any protected activity or personnel action may delay the processing of your
complaint by OSC; and (2) a comprehensive listing will help avoid disputes in any
later Individual Right of Action (IRA) appeal that you may file with the Merit
Systems Protection Board (MSPB).

Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information

You may add additional allegations of retaliation for engaging in protected activities
to this complaint while it is pending at OSC. Submission of any additional
allegations to OSC in writing will help you if you later decide to file an IRA appeal
with the MSPB.

Your Complaint
Retaliation for
Whistleblowing

To establish its jurisdiction over an IRA appeal, the MSPB will require you to show
that your IRA appeal relates to the same protected activities and personnel
action(s) raised in your complaint to OSC. The following documents will help meet
this requirement: a copy of the retaliation allegations in your complaint, any
additional allegation(s) of retaliation that you submitted to OSC in writing while the
complaint was pending, and any official correspondence you receive from OSC
about your complaint. IT IS IMPORTANT, THEREFORE, THAT YOU SAVE
COPIES OF ALL THESE DOCUMENTS FOR YOUR RECORDS.

Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition

If OSC fails to complete its review of your retaliation 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).

Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference

Please briefly answer the following questions about your retaliation claim. If
there is more than one instance, you may repeat the process until you have
answered the questions for each instance. To do so, click the “Add Another
Retaliation for Protected Activity Claim” button at the end of this section. You
Other Bases of
Discrimination
will have an opportunity to attach supporting documentation before you submit
your
form.
Improper Personnel Actions
Delete the Retaliation for
Non-Disclosure Agreement
Protected Activity Claim Below
Improper Accessing of
1. In what protected activity did you engage?
Medical Records
Filed a complaint, appeal, or grievance
Coerce Political Activity
Testified for or lawfully assisted an individual in the exercise of their right to file
Other
a complaint, appeal, or grievance
Cooperated with or disclosed information to an Inspector General, OSC, or
Attachments
other investigator
Consent
Refused to obey an order that would require you to violate a law, rule, or
Certification
regulation
Other
Submission
Discrimination for
Non-Job-Related Conduct

2. When did you engage in the protected activity?

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
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3. Please briefly describe the nature of your protected activity.

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition

4. What action did the agency take in response to your protected activity? (For
example, did the agency investigate or otherwise look into what you disclosed or
was disciplinary action taken against responsible agency officials?)

5. When and how did agency officials learn about your protected activity?

6. What personnel action(s) do you believe was taken, not taken, or threatened
because of your disclosure?
Check all applicable:
Removal
Reinstatement
Suspension

Reassignment

Other Discipline

Harassment/Hostile Work Environment

VA Expedited Process

Psychiatric Examination

Nepotism

Gag Order

Performance Evaluation

Improper Political
Recommendation

Detail

Changes to Duties/Working Conditions

Promotion

Pay, Benefits, Training

Appointment

Other

Give Unauthorized
Preference
Encourage Withdrawal from
Competition

Violate Veterans’
Preference

Describe:

Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination

7. When was the personnel action(s) taken? By whom?

Improper Personnel Actions
Non-Disclosure Agreement

8. What was the agency’s stated reason for taking the personnel action(s)?

Improper Accessing of
Medical Records
Coerce Political Activity
Other

9. What facts demonstrate that the personnel action(s) is retaliatory? (For example,
were comments made that suggest that agency officials were angry because of
your protected activity or did your relationships cool following your actions?)

Attachments
Consent
Certification
Submission

10. Why do you believe agency officials would retaliate against you? (For example, did
agency officials suffer some adverse impact or embarrassment because of your
protected activity?)

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Add / Delete a Complaint

11. Please provide the name, title, and position in your chain of command of the agency
official(s) involved in taking the personnel action(s) that you believe were retaliatory.

Prohibited Personnel
Practices (PPP)

First Name

Last Name

Chain of Command
Title
(e.g., Deputy Director) (e.g., 1st level supervisor)

About Filing a Complaint

Del

Select your PPPs
Add Row

Biographical Information
Your Complaint
Retaliation for
Whistleblowing

12. Were the agency officials involved in taking the personnel action(s) against you
accused of wrongdoing in your complaint or other protected activity? If yes, which
ones?

Retaliation for Protected
Activity
Add Another Retaliation for
Protected Activity Claim

Obstruct Competition
Give Unauthorized
Preference

Obstructed Competition

Encourage Withdrawal from
An agency official is prohibited from deceiving or willfully obstructing an
Competition
individual from competing for federal employment. 5 U.S.C. § 2302(b)(4). This section
requires evidence that the agency official willfully engaged in actions to prevent or
Nepotism
otherwise adversely affect an individual from being considered for a position. A
Improper Political
mistake, oversight, or error is not a prohibited personnel practice. Likewise, the
Recommendation
selection of a qualified candidate who, at the outset of the competition, was the
Violate Veterans’
preferred candidate (i.e., “pre-selection”) does not automatically constitute a willful
Preference
obstruction of one’s right to compete.
Discrimination for
Please briefly answer the following questions about your claim of willful
Non-Job-Related Conduct obstruction. If there is more than one instance, you may repeat the process until
you have answered the questions for each instance. To do so, click the “Add
Other Bases of
Discrimination
Another Obstructed Competition Claim” button at the end of this section. You
will have an opportunity to attach supporting documentation before you submit
Improper Personnel Actions
your form.
Non-Disclosure Agreement
Delete the Obstructed
Improper Accessing of
Competition Claim Below
Medical Records
1. State the series, grade, and title of the position for which you were competing, if
Coerce Political Activity
applicable.
Other
Attachments

2. How was the position filled (e.g., vacancy announcement, detail, reassignment)?

Consent
Certification
Submission

3. Was the position in the competitive or excepted service?
Competitive Service
Excepted Service
4. Was the position advertised?

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

Yes

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
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If yes, what is the vacancy announcement number and when was it advertised?

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information

5. How was this position advertised? (Check all that apply.)
Externally
Internally
6. Did you apply for the position?
If no, why?

Yes

Your Complaint
Retaliation for
Whistleblowing

7. State the name and title of the agency official(s) who deceived or obstructed you
from competing for federal employment.

Retaliation for Protected
Activity

First Name

Last Name

Title (e.g., Deputy Director)
Del

Obstruct Competition
Give Unauthorized
Preference

Add Row

Encourage Withdrawal from
8. State how the involved agency official(s) deceived or obstructed you from
Competition
competing for federal employment. (For example, what did he/she say or do to
Nepotism
obstruct you from competing?)
Improper Political
Recommendation
9. Why do you believe the identified agency official(s) wanted to obstruct your right to
Violate Veterans’
compete?
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination

Add Another Obstructed
Competition Claim

Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent
Certification
Submission

Give Unauthorized Preference
An agency official is prohibited from granting an unauthorized preference or
advantage to any employee or applicant for the purpose of improving or injuring the
prospects of any particular person for employment.5 U.S.C. § 2302(b)(6). Please note
that the selection of a qualified candidate who, at the outset of the competition, was the
preferred candidate (i.e., “pre-selection”) does not alone constitute an unauthorized
preference or advantage.
Please briefly answer the following questions about your unauthorized
preference or advantage claim. If there is more than one instance, you may repeat
the process until you have answered the questions for each instance. To do so,
click the “Add Another Give Unauthorized Preference Claim” button at the end of
this section. You will have an opportunity to attach supporting documentation
before you submit your form.

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Delete the Give Unauthorized
Preference Claim Below

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)
About Filing a Complaint
Select your PPPs
Biographical Information

1. Please state the job title, series, and grade of the position for which an
unauthorized preference or advantage was granted.

2. How was the position filled (e.g., vacancy announcement, detail, reassignment)?

Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition

3. Was the position in the competitive or excepted service?
Competitive Service

Excepted Service

4. Was the position advertised?
Yes
No
If yes, what is the vacancy announcement number and when was it advertised?

Give Unauthorized
Preference

5. How was this position advertised? (Check all that apply.)
Externally
Internally
N/A
Encourage Withdrawal from
Competition
6. State the name and title of the agency official(s) who granted the unauthorized
preference or advantage.
Nepotism
Improper Political
Recommendation

First Name

Last Name

Title (e.g., Deputy Director)
Del

Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination

Add Row

7. State the name, title, and position (if applicable) of the person who received the
unauthorized preference or advantage.

Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records

8. How did the involved agency official(s) advantage this person? (For example, what
specific actions did the agency official take to improve the employment prospects of
this person?)

Coerce Political Activity
Other

9. What motivated the agency official to advantage this person?

Attachments
Consent
Certification
Submission

10. What facts indicate that the involved agency official(s) granted the unauthorized
preference or advantage for the purpose of improving this person’s chances of
being selected?

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

11. If you believe the person selected was not qualified for the position, which of the
required qualification(s) does the individual lack? How do you know the individual
does not meet the requirement(s)?

About Filing a Complaint
Add Another Give Unauthorized
Preference Claim

Select your PPPs
Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition

Encourage Withdrawal from Competition
An agency official is prohibited from influencing, or trying to influence, an
individual to withdraw from competition for any position for the purpose of improving or
injuring the prospects of any other person for employment. 5 U.S.C. § 2302(b)(5).
Please briefly answer the following questions about your claim concerning
improper influence. If there is more than one instance, you may repeat the process
until you have answered the questions for each instance. To do so, click the
“Add Another Encourage Withdrawal from Competition Claim” button at the end
of this section You will have an opportunity to attach supporting documentation
before you submit your form.
Delete the Encourage Withdrawal
from Competition Claim Below

Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference

1. State the series, grade, and title of the position for which you were competing.

2. How was the position filled (e.g., vacancy announcement, detail, reassignment)?

Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination

3. Was the position in the competitive or excepted service?
Competitive Service
Excepted Service

Improper Personnel Actions 4. Was the position advertised?
Yes
No
If yes, what is the vacancy announcement number and when was it advertised?
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments

5. How was this position advertised? (Check all that apply.)
Externally
Internally
6. Did you apply for the position?
If no, why?

Yes

Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Add / Delete a Complaint

7. State the name and title of the agency official(s) who influenced, or tried to
influence, you to withdraw from competition.

Prohibited Personnel
Practices (PPP)

First Name

Last Name

Title (e.g., Deputy Director)
Del

About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition

Add Row

8. State how the involved agency official(s) influenced, or tried to influence, you to
withdraw from competition.

9. What facts indicate that the agency official sought to improve or injure someone’s
chances of being selected? (For example, did someone benefit from your
withdrawal? Would someone have benefited had you withdrawn?)

Give Unauthorized
Preference

Add Another Encourage Withdrawal
from Competition Claim

Encourage Withdrawal from
Competition

Nepotism

A public official is prohibited from engaging in nepotism (i.e., hiring, promoting,
advancing, or advocating for the appointment, employment, promotion, or
advancement of any relative). 5 U.S.C. 2302(b)(7). The word “relative,” means a father,
Violate Veterans’
mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece,
Preference
husband, wife, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law,
sister-in-law,
stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister,
Discrimination for
Non-Job-Related Conduct half-brother, or half-sister. 5 U.S.C. § 3110(a)(3).
Please briefly answer the following questions about your nepotism claim. If
Other Bases of
there
is
more than one instance, you may repeat the process until you have
Discrimination
answered the questions for each instance. To do so, click the “Add Another
Improper Personnel Actions
Nepotism Claim” button at the end of this section. You will have an opportunity
Non-Disclosure Agreement to attach supporting documentation before you submit your form.
Improper Political
Recommendation

Improper Accessing of
Medical Records
Coerce Political Activity

Delete the Nepotism Claim Below
1. State the name and title of the public official(s) who engaged in nepotism.

Other

First Name

Last Name

Title (e.g., Deputy Director)

Attachments

Del

Consent
Add Row

Certification
Submission

2. Identify the relative for whom the official acted or advocated.

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

3. How is the public official related to the person for whom s/he acted or advocated?
How do you know that they are related?

4. When and how did the public official play a part in appointing, employing,
promoting, advancing, or advocating for his/her relative?

Select your PPPs
Biographical Information
Your Complaint

5. To your knowledge, has anyone previously alleged nepotism based on the
relationship between this public official and his/her relative?
Yes
No
If yes, what was the outcome?

Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition

Add Another Nepotism Claim

Give Unauthorized
Preference
Encourage Withdrawal from
Competition
Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination

Improper Political Recommendation
An agency official is prohibited from soliciting or considering any employment
recommendation or statement, unless it is based on personal knowledge.
5 U.S.C. § 2302(b)(2). This section is intended to prevent the use of political influence
to obtain a position or promotion.
Please briefly answer the following questions about your claim of an improper
recommendation. If there is more than one instance, you may repeat the process
until you have answered the questions for each instance. To do so, click the
“Add Another Improper Political Recommendation Claim” button at the end of
this section. You will have an opportunity to attach supporting documentation
before you submit your form.
Delete the Improper Political
Recommendation Claim Below

Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity

1. Describe the employment recommendation that was solicited or considered. (For
example, for what employment opportunity was it solicited or considered? When
was it issued? Who was the beneficiary or intended beneficiary of the
recommendation?)

Other
Attachments

2. How did you learn about the solicitation or consideration of the recommendation?

Consent
Certification
Submission

3. State the name and title of the agency official(s) who solicited or considered the
recommendation.

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar

First Name

Add / Delete a Complaint

Last Name

Title (e.g., Deputy Director)
Del

Prohibited Personnel
Practices (PPP)
Add Row

About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity

4. Was the recommendation received from a member of Congress? If so, (a) please
identify the member of Congress, and (b) describe the nature of the
recommendation.

5. If an employment recommendation was made, was it based on the personal
knowledge of the person who made it? For example, was the recommendation
based on observations derived from an employment relationship?

Obstruct Competition
Give Unauthorized
Preference

6. If you believe that an employment recommendation was not based on the personal
knowledge of the person who made it, please describe the facts supporting your
belief.
Encourage Withdrawal from
Competition
Nepotism
Improper Political
Recommendation

Add Another Improper Political
Recommendation Claim

Violation of Veterans' Preference
An agency official is prohibited from taking or failing to take a
personnel action if doing so would violate veterans' preference. 5 U.S.C. § 2302(b)(11).
While such actions constitute a prohibited personnel practice, generally, employees
must file these claims through the Department of Labor. More information on filing
these complaints with DOL can be found on their website.

Discrimination for Non-Job-Related Conduct
An agency official is prohibited from discriminating against an employee or
applicant on the basis of conduct that does not adversely affect the performance of the
employee or applicant, or the performance of others. 5 U.S.C. § 2302(b)(10). This could
include, for example, discrimination based on sexual orientation or gender identity.
Please briefly answer the following questions about your discrimination claim to
help OSC determine whether there is sufficient information to warrant further inquiry
into this allegation. If there is more than one instance, you may repeat the process
until you have answered the questions for each instance. To do so, click the
“Add Another Discrimination for Non-Job-Related Conduct Claim” button at the
end of this section. You will have an opportunity to attach supporting
documentation before you submit your form.

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)

1. For what conduct do you believe you have faced discrimination?

About Filing a Complaint
Select your PPPs
Biographical Information
Your Complaint

2. Does your conduct involve your sexual orientation?
3. Does your conduct involve your gender identity?

Yes
No
Yes
No
4. When and where did you engage in this conduct? (For example, did it occur before/
after duty hours, away from work?)

Retaliation for
Whistleblowing
Retaliation for Protected
Activity

5. State the name, title, and position in your chain of command of the agency official(s)
who discriminated against you based on your conduct.

Obstruct Competition

First Name

Last Name

Give Unauthorized
Preference

Chain of Command
Title
(e.g., Deputy Director) (e.g., 1st level supervisor)
Del

Encourage Withdrawal from
Competition

Add Row

Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct

6. If you know, state when and how the agency official(s) learned of your conduct.

7. State how the agency official(s) discriminated against you based on your conduct.
Check all applicable:
Removal

Reinstatement

Suspension

Reassignment

Other Discipline

Harassment/Hostile Work Environment

VA Expedited Process

Psychiatric Examination

Gag Order

Performance Evaluation

Detail

Changes to Duties/Working Conditions

Coerce Political Activity

Promotion

Pay, Benefits, Training

Other

Appointment

Other

Other Bases of
Discrimination
Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records

Describe:

Attachments
Consent
Certification
Submission

8. What facts indicate that the involved agency official(s) discriminated against you
based on your conduct? (For example, did the agency official(s) make negative
comments about your conduct? Were other employees who did not engage in such
conduct treated differently from you?)

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar
Add Another Discrimination for
Non-Job-Related Conduct Claim

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)
About Filing a Complaint

Other Bases of Discrimination
(Based on Race, Color, Religion, Sex, National Origin, Age, Disability, Marital Status, or Political Affiliation)

An agency official is prohibited from discriminating for or against any employee
or applicant for employment on the basis of race, color, religion, sex, national origin,
Biographical Information
age, disability (or handicapping condition), marital status or political affiliation.
5 U.S.C. § 2302(b)(1). OSC routinely examines claims of discrimination based on
Your Complaint
marital status and political affiliation. However, we defer nearly all claims of
Retaliation for
discrimination based on race, color, religion, sex, national origin, age, disability (or
Whistleblowing
handicapping condition) to the EEO process. Filing an OSC complaint based upon one
of these bases will not change the deadlines for filing an EEO complaint. While
Retaliation for Protected
allegations of sexual orientation and gender identity discrimination are also sex
Activity
discrimination, OSC also examines these allegations as complaints of
Obstruct Competition
Discrimination for Non-Job-Related Conduct. If you are making an allegation of
Give Unauthorized
sexual orientation or gender identity discrimination, please complete the
Preference
questions for that section.
Please briefly answer the following questions about your discrimination claim. If
Encourage Withdrawal from
there is more than one instance, you may repeat the process until you have
Competition
answered the questions for each instance. To do so, click the “Add Another
Nepotism
Other Bases of Discrimination Claim” button at the end of this section. You will
have an opportunity to attach supporting documentation before you submit your
Improper Political
Recommendation
form.
Select your PPPs

Violate Veterans’
Preference

Delete the Other Bases of
Discrimination Claim Below

Discrimination for
Non-Job-Related Conduct

1. What is the basis of your discrimination claim?
Race
National Origin
Other Bases of
Color
Age
Discrimination
Religion
Marital Status
Improper Personnel Actions
Sex
Political Affiliation
Disability
(or
handicapping
condition)
Non-Disclosure Agreement
2. What is your status within that basis? (For example, if you are claiming marital
Improper Accessing of
status discrimination, are you married, single, widowed, or separated?)
Medical Records
Coerce Political Activity
Other
Attachments

3. What action(s) did the agency take or fail to take?
Check all applicable:

Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

Removal

Reinstatement

Suspension

Reassignment

Other Discipline

Harassment/Hostile Work Environment

VA Expedited Process

Psychiatric Examination

Gag Order

Performance Evaluation

Detail

Changes to Duties/Working Conditions
OMB No. 3255-0005
Expires 09/30/2020

Promotion

Pay, Benefits, Training

Appointment

Other

Describe:

About Filing a Complaint
Select your PPPs

4 When did the action(s) occur?

Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity

5. State the name, title, and position in your chain of command of the agency official(s)
involved in the action(s).
Chain of Command
Title
First Name
Last Name
(e.g., Deputy Director) (e.g., 1st level supervisor)
Del

Obstruct Competition
Give Unauthorized
Preference

Add Row

Encourage Withdrawal from 6. What was the agency’s stated reason(s) for the action(s)?
Competition
Nepotism
Improper Political
Recommendation

7. What facts support your assertion that the action was discriminatory?

Violate Veterans’
Preference

Add Another Other Bases of
Discrimination Claim

Discrimination for
Non-Job-Related Conduct

Improper Personnel Actions

Other Bases of
Discrimination

An agency official is prohibited from taking or failing to take a personnel action
if
doing
so
results in the violation of a law, rule, or regulation that implements, or
Improper Personnel Actions
directly concerns, a merit system principle listed in 5 U.S.C. § 2301.
Non-Disclosure Agreement 5 U.S.C. § 2302(b)(12). Retaliation for petitioning a member of Congress or exercising
your First Amendment rights falls under this section.
Improper Accessing of
Medical Records
Please briefly answer the following questions about your claim under this
section. If there is more than one instance, you may repeat the process until you
Coerce Political Activity
have answered the questions for each instance. To do so, click the “Add Another
Other
Improper Personnel Actions Claim” button at the end of this section. You will
have an opportunity to attach supporting documentation before you submit your
Attachments
form.
Consent
Delete the Improper Personnel
Certification
Actions Claim Below
Submission

1. What was the personnel action(s) taken or not taken?
Check all applicable:
Removal

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

Reinstatement

OMB No. 3255-0005
Expires 09/30/2020

COMPLAINT OF PROHIBITED PERSONNEL PRACTICE OR OTHER
PROHIBITED ACTIVITY
For instructions or questions, call the Case Review Division at (202) 804-7000.
Navigation Bar

Suspension

Reassignment

Other Discipline

Harassment/Hostile Work Environment

VA Expedited Process

Psychiatric Examination

About Filing a Complaint

Gag Order

Performance Evaluation

Select your PPPs

Detail

Changes to Duties/Working Conditions

Biographical Information

Promotion

Pay, Benefits, Training

Your Complaint

Appointment

Other

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)

Describe:

Retaliation for
Whistleblowing
Retaliation for Protected
Activity

2. When was the personnel action(s) taken or not taken?

Obstruct Competition
Give Unauthorized
Preference

3. State the name, title, and position in your chain of command of the agency official(s)
involved in the personnel action(s).
Encourage Withdrawal from
Chain of Command
Title
First Name
Last Name
Competition
(e.g., Deputy Director) (e.g., 1st level supervisor)
Nepotism
Del

Improper Political
Recommendation
Violate Veterans’
Preference
Discrimination for
Non-Job-Related Conduct

Add Row

4. Describe the role played by each agency official listed above in the personnel
action(s) that is the subject of your complaint. (e.g., recommending official,
proposing official, deciding official, approving official, etc.).

Other Bases of
Discrimination
Improper Personnel Actions 5. What law, rule, or regulation was violated by the agency’s taking or failing to take
the personnel action(s)?
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity

Add Another Improper Personnel
Actions Claim

Other
Attachments
Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

Non-Disclosure Agreement
An agency official is prohibited from implementing or enforcing a nondisclosure policy, form, or agreement (commonly called a “gag order”) if it does not
contain a statement notifying employees and applicants for federal employment of their
rights, obligations, and liabilities concerning classified information, communications to
Congress, whistleblowing to an Inspector General, or any other whistleblower
protection. 5 U.S.C. § 2302(b)(13).
Please briefly answer the following questions about this claim. If there is more
than one instance, you may repeat the process until you have answered the
questions for each instance. To do so, click the “Add Another Non-Disclosure
Agreement Claim” button at the end of this section. You will have an opportunity
to attach supporting documentation before you submit your form.

Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference

Delete the Non-Disclosure
Agreement Claim Below
1. Describe the non-disclosure policy or “gag order.”

Encourage Withdrawal from
2. State the name, title, and position in your chain of command of the agency official(s)
Competition
who implemented or enforced the non-disclosure agreement or policy.
Nepotism
Chain of Command
Title
First Name
Last Name
Improper Political
(e.g., Deputy Director) (e.g., 1st level supervisor)
Recommendation
Del

Add Row

3. When was the agreement or policy issued?

4. To whom does the agreement or policy apply (i.e., does the agreement apply only
to you, to the subordinates of a particular agency official(s), to a field office, or to
the entire agency?)

5. Does the agreement or policy contain a statement concerning whistleblower rights?

Other

Yes

Attachments
Add Another Non-Disclosure
Agreement Claim

Consent
Certification
Submission

Improper Accessing of Medical Records
An agency official is prohibited from accessing the medical records of another
employee or applicant for employment as a part of, or otherwise in furtherance of, the
commission of a prohibited personnel practice.5 U.S.C. § 2302(b)(14).

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

Please briefly answer the following questions about your claim. If there is
more than one instance, you may repeat the process until you have answered the
questions for each instance. To do so, click the “Add Another Improper
Accessing of Medical Records Claim” button at the end of this section. You will
have an opportunity to attach supporting documentation before you submit your
form.
Delete the Improper Accessing of
Medical Records Claim Below

Biographical Information
Your Complaint

1. Who accessed your medical records?

Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition
Nepotism

2. When were they accessed?

3. Please provide any additional details you may have to describe how your records
were accessed.

4. What reason did the agency give to explain why they accessed your medical
records? Why do you think they did so?

Improper Political
Recommendation
Violate Veterans’
Preference

5. What action, if any, did the agency take based on information learned from your
medical records?

Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination

6. Do you think that agency officials improperly accessed your medical records in
connection with one of the other PPPs listed on this form? If so, please describe.

Improper Personnel Actions
Non-Disclosure Agreement
Add Another Improper Accessing
of Medical Records Claim

Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent
Certification
Submission

Coerce Political Activity
An agency official is prohibited from coercing a person to engage in political
activity, and from taking action against a person for refusing to do so. This section
prohibits the coercion of a person's political activity, including providing any political
contribution or service. 5 U.S.C. § 2302(b)(3).
Please briefly answer the following questions about your claim of coerced
political activity. If there is more than one instance, you may repeat the process
until you have answered the questions for each instance. To do so, click the
“Add Another Coerce Political Activity Claim” button at the end of this section.
You will have an opportunity to attach supporting documentation before you
submit your form.

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

Add / Delete a Complaint
Prohibited Personnel
Practices (PPP)

1. Describe the political activity or service you were coerced into undertaking.

About Filing a Complaint
Select your PPPs

2. How did an agency official attempt to coerce political activity?

Biographical Information
Your Complaint
Retaliation for
Whistleblowing
Retaliation for Protected
Activity
Obstruct Competition

3. When did the coercion occur?
4. State the name, title, and position in your chain of command of the agency official(s)
involved in the coercion.
Chain of Command
Title
First Name
Last Name
(e.g., Deputy Director) (e.g., 1st level supervisor)

Give Unauthorized
Preference

Del

Encourage Withdrawal from
Competition
Nepotism
Improper Political
Recommendation
Violate Veterans’
Preference

Add Row

5. Why did you feel coerced? (For example, what were the stated or implied adverse
consequences for refusal to participate in the political activity or service?)

6. Have you also filed a Hatch Act complaint with OSC based on this incident?

Discrimination for
Non-Job-Related Conduct
Other Bases of
Discrimination

Yes

No
Add Another Coerce Political
Activity Claim

Improper Personnel Actions
Non-Disclosure Agreement
Improper Accessing of
Medical Records
Coerce Political Activity
Other
Attachments
Consent
Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

Other
OSC also has jurisdiction over certain other activities prohibited by statute. If none of
the categories of wrongdoing above apply to your circumstances, please tell us the
basis of your complaint below. OSC will determine whether we have jurisdiction over
your complaint. You will have an opportunity to attach supporting documentation
before you submit your form.

Biographical Information
Your Complaint
Retaliation for
Whistleblowing

Attachments
I would like to attach documents to my complaint.

ATTACH

Please note that the space available for attachments is limited. Therefore, DO NOT
attach every document and email that may be relevant to your claim. You will have an
opportunity to make additional submissions at a later date. We recommend limiting
attachments to official forms and correspondence that document the action(s) at issue
Obstruct Competition
in your complaint (e.g., proposed AND final disciplinary action, along with any written
Give Unauthorized
reply you submitted; letter of reprimand; performance appraisal; PIP; vacancy
Preference
announcement) if these documents are relevant to your allegations.
Encourage Withdrawal from To see the attachments that have been successfully added to your form, click on the
Competition
paperclip icon
in the dark gray panel on the far left side of your screen. Please note
that,
if
you
print
a
copy
of your form, the attachments will not print with it. However, any
Nepotism
documents that appear in the paperclip panel
will be transmitted to OSC.
Improper Political
Recommendation
Retaliation for Protected
Activity

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

PART 5: CONSENT TO CERTAIN DISCLOSURES OF INFORMATION
* Denotes Required Fields
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. Please: (a) select and check one of the Consent Statements below; and (b)
keep a copy 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 and other applicable federal laws allow
information in OSC case files to be used or disclosed for certain purposes, regardless
of which Consent Statement you sign. Information about certain circumstances under
which OSC can use or disclose information under the Privacy Act appears in the Form
Submission part of this form.

*(Please check ONLY one)

Obstruct Competition
Give Unauthorized
Preference
Encourage Withdrawal from
Competition

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 and information about my complaint if OSC decides
that such disclosure is needed to investigate my complaint (for example, to request
information from the agency, or seek a possible resolution).

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 to that agency. I agree to allow OSC to
disclose only information about my complaint, without disclosing my name or other
identifying information, if OSC decides that such disclosure is needed to investigate my
complaint (for example, to request information from the agency, or seek a possible
resolution). I understand that in some circumstances, OSC could not maintain my
anonymity while communicating with the agency involved about a specific personnel
action. In such cases, I understand that my request for confidentiality may prevent OSC
from taking further action on the complaint.
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 my complaint without
communicating with that agency, my lack of consent will probably prevent OSC from
taking further action on the complaint.

Attachments
Consent

Certification
Submission

OSC Form-14
PROHIBITED PERSONNEL PRACTICES
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

PART 1: IMPORTANT INFORMATION ABOUT FILING A DISCLOSURE
OSC WHISTLEBLOWER DISCLOSURE CHANNEL

Violation of Law,Rule, or
Regulation

Under 5 U.S.C. § 1213 and related provisions, the Office of Special Counsel (OSC)
serves as a secure channel for federal employees, former federal employees, and
applicants for federal employment with reliable knowledge of the wrongdoing to
disclose:
• a violation of law, rule or regulation;
• gross mismanagement;
• gross waste of funds;
• an abuse of authority;
• a substantial and specific danger to public health or safety; and/or
• censorship related to scientific research.

Gross Mismanagement

OSC JURISDICTION

Gross Waste of Funds

Attachments

OSC has no jurisdiction over disclosures filed by:
• employees of the U.S. Postal Service and the Postal Regulatory Commission;
• members of the armed forces of the United States (i.e., non-civilian military
employees);
• state employees operating under federal grants;
• employees of federal contractors;
• other employees or federal agencies that are exempt under federal law; and
• Congressional or judicial branch employees.

Consent

ANONYMOUS SOURCES

About Filing a Disclosure
Biographical Information
Details of Your Disclosure
Select Your Disclosures
Your Disclosure

Abuse of Authority
Danger to Public Health
Danger to Public Safety
Censorship Related to
Scientific Research

Certification
Submission

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.

RETALIATION
Do you believe you suffered retaliation by your agency for disclosing wrongdoing? If
yes, you may file a complaint for retaliation by selecting Add/Delete a Complaint from
the top left corner. Select Option 1 to complete and submit a Complaint of Prohibited
Personnel Practice or other Prohibited Activity (PPPs). If you have already completed
the Complaint of Prohibited Personnel Practice or other Prohibited Activity above,
please continue with this Disclosure. PPPs are employment-related activities that are
banned in the federal workforce. PPPs generally involve some type of personnel
decision or action and may result in personal relief for people who have been subject to
a PPP. For example, if we find that you were removed from federal service in
retaliation for whistleblowing, OSC may act to get your job back. PPPs can also
include allegations of harassment, failure to issue appraisals, and improper hiring. Do
not file a disclosure to report retaliation or other PPPs.

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

REPORT GOVERNMENT WRONGDOING (DISCLOSURE)
Do not use this form to submit classified information.
For instructions or questions, call the Disclosure Unit at (202) 804-7000.
Navigation Bar

PART 2: BIOGRAPHICAL INFORMATION

Add / Delete a Complaint
Report Government
Wrongdoing (Disclosure)

* Denotes Required Fields
1. Complainant Information:

About Filing a Disclosure

Title

Biographical Information

First Name*

Details of Your Disclosure

Last Name*

Select Your Disclosures
Your Disclosure
Violation of Law,Rule, or
Regulation

Middle Initial

2. Contact Information:
Address Location*

Domestic

International

Address Line 1*

Gross Mismanagement

Address Line 2

Gross Waste of Funds

City*

Abuse of Authority

Zip Code*

Danger to Public Health

*At least ONE phone number OR email address is required.

Danger to Public Safety

Cell Phone Number

Censorship Related to
Scientific Research

Office Phone Number

Attachments
Consent
Certification
Submission

State*

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

home phone

cell phone

office phone

Please do not contact me on my office phone
International Address*
*At least ONE phone number OR email address is required.
Cell Phone Number
Office Phone Number

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

home phone

cell phone

office phone

Please do not contact me on my office phone

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

3. Do you have representation?*

First Name*

Middle Initial

Last Name*

Biographical Information

Address Location*

Details of Your Disclosure

Address Line 1*

Select Your Disclosures

Address Line 2

Your Disclosure

City*

Gross Mismanagement
Gross Waste of Funds
Abuse of Authority
Danger to Public Health
Danger to Public Safety
Censorship Related to
Scientific Research
Attachments

Title

About Filing a Disclosure

Violation of Law,Rule, or
Regulation

Yes

Domestic

International

State*

Zip Code*
*At least ONE phone number OR email address is required.
Cell Phone Number
Office Phone Number

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

home phone

cell phone

office phone

International Address*

Consent
Certification
Submission

*At least ONE phone number OR email address is required.
Cell Phone Number
Office Phone Number

Ext.

Home Phone Number
Email Address
Preferred means of contact:
email

home phone

cell phone

office phone

4. Complainant’s employment status:*
Current Federal Employee
Former Federal Employee
Applicant For Federal Employment
Non-Federal Employee (please specify below)

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

REPORT GOVERNMENT WRONGDOING (DISCLOSURE)
Do not use this form to submit classified information.
For instructions or questions, call the Disclosure Unit at (202) 804-7000.
Navigation Bar
Add / Delete a Complaint
Report Government
Wrongdoing (Disclosure)
About Filing a Disclosure
Biographical Information
Details of Your Disclosure
Select Your Disclosures
Your Disclosure

5. If current or former federal employee, please list most recent position title, series,
grade:
Title (for instance, Investigator)
Series (for instance, GS-1810)
Grade (for instance, GS-9)
6. Please provide your dates of employment in this position.
7. Department name:*
8. Agency name:*

Violation of Law,Rule, or
Regulation

9. Agency subcomponent:

Gross Mismanagement

10.Street Address:

Gross Waste of Funds

11. City:*

Abuse of Authority

12. State:*

Danger to Public Health
Danger to Public Safety
Censorship Related to
Scientific Research

Check here if agency address is international*

Country:*
13. Zip Code:

Attachments

14.Are you covered by a collective bargaining agreement? (Check one.)
Yes
No
I don't know

Consent

15.Which of the following apply to your employment status? (Check all applicable items.)

Certification
Submission

a. Competitive Service
Temporary appointment
Term appointment

Career or career-conditional appointment
Probationary employee

b. Excepted Service
Schedule A
National Guard/Reserve Tech
Tennessee Valley Authority

Schedule B
Schedule C
Postal Service
Non-appropriated fund

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

Military officer or enlisted person
Contract employee
Other (specify):

OMB No. 3255-0005
Expires 09/30/2020

PART 3: SELECT YOUR DISCLOSURES
Please identify the type of wrongdoing that you are alleging (check ALL that apply - you
MUST check one option). If you check "violation of law, rule, or regulation," specify, if
you can, the particular law, rule or regulation violated (by name, subject, and/or legal
citation).
Violation of law, rule, or regulation (please specify):

Select Your Disclosures
Your Disclosure
Violation of Law,Rule, or
Regulation

Gross mismanagement
Gross waste of funds
Abuse of authority

Gross Mismanagement

Substantial and specific danger to public health

Gross Waste of Funds

Substantial and specific danger to public safety

Abuse of Authority

Censorship related to scientific research

Danger to Public Health
Danger to Public Safety
Censorship Related to
Scientific Research
Attachments
Consent
Certification
Submission

For each allegation, please answer the following questions (be as specific as possible).
Please keep in mind that you will have an opportunity to provide more information and
someone from OSC will contact you.
If OSC determines there is a substantial likelihood of wrongdoing, OSC will refer your
disclosures to the involved agency for an investigation and report. To meet the
substantial likelihood standard, there must be a significant probability that the
information reveals wrongdoing that falls within one or more of the categories above.
In its evaluation, OSC considers the strength, reliability, and credibility of the
disclosures. If the substantial likelihood determination cannot be made, OSC will
determine whether there is sufficient information to exercise its discretion to refer the
allegations.
If there is more than one instance, you may repeat the process until you have
answered the questions for each instance. To do so, click the “Add Another
Instance” button at the end of each section. You will have an opportunity to
attach supporting documentation before you submit your form.

Violation of law, rule, or regulation

Delete the Violation
of Law Claim Below

a. Who took the action?
First Name

Last Name

Title
Del

Add Row

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

REPORT GOVERNMENT WRONGDOING (DISCLOSURE)
Do not use this form to submit classified information.
For instructions or questions, call the Disclosure Unit at (202) 804-7000.
Navigation Bar

b. What action did they take?

Add / Delete a Complaint
Report Government
Wrongdoing (Disclosure)
About Filing a Disclosure

c. When did this action occur?
d. How did you discover this action?

Biographical Information
Details of Your Disclosure
Select Your Disclosures

e. What additional facts support your allegation of a violation of law, rule, or
regulation?

Your Disclosure
Violation of Law,Rule, or
Regulation

Add Another Violation of
Law, Rule, or Regulation Claim

Gross Mismanagement
Gross Waste of Funds
Abuse of Authority
Danger to Public Health
Danger to Public Safety

Gross mismanagement

Delete the Gross
Mismanagement Claim Below

a. Who took the action?
First Name

Last Name

Title

Censorship Related to
Scientific Research
Attachments
Consent

Del
Add Row

b. What action did they take?

Certification
Submission

c. When did this action occur?
d. How did you discover this action?

e. What additional facts support your allegation of gross mismanagement?

Add Another Gross
Mismanagement Claim

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

Gross waste of funds

Delete the Gross
Waste of Funds Claim Below

a. Who took the action?
First Name

Last Name

Title

About Filing a Disclosure

Del

Biographical Information
Details of Your Disclosure
Select Your Disclosures

Add Row

b. What action did they take?

Your Disclosure
Violation of Law,Rule, or
Regulation

c. When did this action occur?

Gross Mismanagement

d. How did you discover this action?

Gross Waste of Funds
Abuse of Authority

e. What additional facts support your allegation of gross waste of funds?

Danger to Public Health
Danger to Public Safety
Censorship Related to
Scientific Research

Add Another Gross
Waste of Funds Claim

Attachments
Consent
Certification
Submission

Abuse of authority

Delete the Abuse
of Authority Claim Below

a. Who took the action?
First Name

Last Name

Title
Del

Add Row

b. What action did they take?

c. When did this action occur?
d. How did you discover this action?

e. What additional facts support your allegation of abuse of authority?

Add Another
Abuse of Authority Claim
OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

Substantial and specific danger
to public health

Delete the Substantial and Specific
Danger to Public Health Claim Below

a. Who took the action?
First Name

Last Name

Title

About Filing a Disclosure

Del

Biographical Information
Details of Your Disclosure
Select Your Disclosures

Add Row

b. What action did they take?

Your Disclosure
Violation of Law,Rule, or
Regulation

c. When did this action occur?

Gross Mismanagement

d. How did you discover this action?

Gross Waste of Funds
Abuse of Authority
Danger to Public Health

e. What additional facts support your allegation of substantial and specific danger
to public health?

Danger to Public Safety
Censorship Related to
Scientific Research

Add Another Substantial and
Specific Danger to Public Health Claim

Attachments
Consent
Certification
Submission

Substantial and specific danger
to public safety

Delete the Substantial and Specific
Danger to Public Safety Claim Below

a. Who took the action?
First Name

Last Name

Title
Del

Add Row

b. What action did they take?

c. When did this action occur?
d. How did you discover this action?

e. What additional facts support your allegation of substantial and specific danger
to public safety?

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

REPORT GOVERNMENT WRONGDOING (DISCLOSURE)
Do not use this form to submit classified information.
For instructions or questions, call the Disclosure Unit at (202) 804-7000.
Navigation Bar

Add Another Substantial and
Specific Danger to Public Safety Claim

Add / Delete a Complaint
Report Government
Wrongdoing (Disclosure)
About Filing a Disclosure
Biographical Information

Censorship related to scientific
research

Delete the Censorship Related to
Scientific Research Claim Below

a. Who took the action?
First Name

Last Name

Title

Details of Your Disclosure

Del

Select Your Disclosures
Your Disclosure
Violation of Law,Rule, or
Regulation

Add Row

b. What action did they take?

Gross Mismanagement
Gross Waste of Funds

c. When did this action occur?

Abuse of Authority

d. How did you discover this action?

Danger to Public Health
Danger to Public Safety
Censorship Related to
Scientific Research

e. What additional facts support your allegation of censorship related to scientific
research?

Attachments
Consent
Certification
Submission

Add Another Censorship Related to
Scientific Research Claim
1. What action would you like OSC to take?

PART 4: WHERE ELSE DID YOU REPORT THIS MATTER?
2. I have also disclosed this information to (complete all that apply):
None or not applicable
Inspector General of department / agency involved

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

Date:

OMB No. 3255-0005
Expires 09/30/2020

a. Who did you contact?
First Name:
Title:
Address:

Details of Your Disclosure

Email Address:

Select Your Disclosures

Telephone Number:

Your Disclosure

Case ID #:

Violation of Law,Rule, or
Regulation

b. What is the status of the matter?

Gross Mismanagement
Gross Waste of Funds

Last Name:

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

Abuse of Authority
Danger to Public Health

Department of Justice

Danger to Public Safety

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

Censorship Related to
Scientific Research
Attachments
Consent

Date:
General Accounting Office (GAO)

Date:

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

Certification
Submission

Date:

Press / media (newspaper, television, other) (please specify):
Date:
Other (please specify):
NOTE: 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.

OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

ATTACHMENTS
The attachments I added in the Prohibited Personnel Practices (PPP) section also
apply to my disclosure.
I would like to add attachments specific to my disclosure.
ATTACH

Danger to Public Health
Danger to Public Safety
Censorship Related to
Scientific Research
Attachments
Consent
Certification
Submission

ATTACHMENTS
I would like to attach documents to my disclosure.

ATTACH

PART 5: CONSENT TO DISCLOSURE OF INFORMATION
* Denotes Required Fields
Do you consent to the disclosure of your identify to others outside OSC if it becomes
necessary in taking further action on this matter?*
I consent to disclosure of my identity.
I do not consent to disclosure of my identity. (Even if you do not consent, OSC
may disclose your identity if necessary due to an imminent danger to public health
or safety or imminent violation of any criminal law. See 5 U.S.C. § 1213(h).)
Next
OSC Form-14
DISCLOSURE OF INFORMATION
Page # of ##

OMB No. 3255-0005
Expires 09/30/2020

U.S. Office of Special Counsel

Navigation Bar
Add / Delete a Complaint
Prohibited Personnel Practices
(PPP)
Certification
Submission

CERTIFICATION
* Denotes Required Fields
I certify that all of the statements made in this complaint 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,
imprisonment, or both 18 U.S.C. § 1001
BURDEN: The burden for this collection of information (including the time for
reviewing instructions, searching existing data sources, gathering the data needed,
and completing and reviewing the form) is estimated to be an average of one hour to
submit a disclosure of information alleging agency wrongdoing, one hour and fifteen
minutes to submit a complaint alleging a prohibited personnel practice or other
prohibited activity, or 30 minutes to submit a complaint alleging prohibited political
activity. Please send any comments about this burden estimate, and suggestions for
reducing the burden, to the U.S. Office of Special Counsel, General Counsel’s Office,
1730 M Street, NW, Suite 218, Washington, DC 20036-4505.
OTHER INFORMATION: An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid
OMB control number.

PLEASE KEEP A COPY OF YOUR COMPLAINT, ANY SUPPORTING
DOCUMENTATION, AND ANY ADDITIONAL ALLEGATIONS THAT YOU SEND
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 would like to print and mail your complaint, please address it to:
U.S. Office of Special Counsel
1730 M Street, NW
Suite 218
Washington, DC 20036
Next

OSC Form-14

OMB No. 3255-0005

U.S Office of Special Counsel
Form Submission
Navigation Bar
Add / Delete a Complaint

Before you submit your complaint to OSC, please take a moment to review the
Prohibited Personnel Practices following Pre-Submission Summary.
(PPP)
Certification
Submission

PRE-SUBMISSION SUMMARY

COMPLAINT OF A HATCH ACT VIOLATION
Based on the information you entered in the preceding form, a complaint will be
submitted to the Office of Special Counsel reporting alleged Hatch Act violation(s)
involving a:

A list of documents attached appears at the bottom of this page. If you have not
attached documents and would like to do so, or if you would like to attach more
documents, please click here to return to that section of the form.
COMPLAINT OF PROHIBITED PERSONNEL PRACTICE
Based on the information you entered in the preceding form, the following Prohibited
Personnel Practice(s) will be submitted to the Office of Special Counsel:
If you would like to include more allegations, please click here to return to the “Select
Your PPPs” section of the form.
A list of documents attached appears at the bottom of this page. If you have not
attached documents and would like to do so, or if you would like to attach more
documents, please click here to return to that section of the form.
FILING A DISCLOSURE WITH OSC
Based on the information you entered in the preceding form, the following
Disclosure(s) will be submitted to the Office of Special Counsel:
If you would like to include more disclosures, please click here to return to the “Select
Your Disclosures” section of the form.
A list of documents attached appears at the bottom of this page. If you have not
attached documents and would like to do so, or if you would like to attach more
documents, please click here to return to that section of the form.
We find that you have successfully attached the following documents:

OSC Form-14

OMB No. 3255-0005

U.S Office of Special Counsel
Form Submission
Navigation Bar
Add / Delete a Complaint
Prohibited Personnel Practices
(PPP)
Certification
Submission

This form requests information that is relevant and necessary to review your
allegations of agency wrongdoing, prohibited personnel practices, or other prohibited
activity within OSC’s jurisdiction. OSC encourages, but does not require, you to use
this form to allege a Hatch Act violation or disclose agency wrongdoing. The U.S.
Office of Special Counsel collects this information in order to process complaints
alleging wrongdoing under its statutory and regulatory authority. Because your
complaint or disclosure is a voluntary action, you are not required to provide any
personal information to OSC in connection with your complaint or disclosure.
However, OSC cannot process incomplete forms lacking necessary information.
ROUTINE USES: OSC uses the information it collects for official purposes. OSC
needs some disclosure of information from its files to fulfill OSC’s disclosure review,
investigative, prosecutorial, and related responsibilities. OSC published descriptions
of its routine uses for information in its files in the Federal Register (F.R.). OSC uses
some information about your complaint or disclosure in depersonalized form for
statistical purposes. Finally, OSC may disclose information from your file as required
by law under the provisions of the Freedom of Information Act and the Privacy Act.
See 5 U.S.C. §§ 552, 552a.

Once you click "Submit", any changes you make to this form will not be transmitted to
OSC. However, you can amend or add information by contacting the attorney/
investigator/examiner assigned to your complaint. You can contact that person by
calling (202) 804-7000.
Please save a copy of your completed form before submitting.

Save
Once you have saved a copy, click the “Submit” button to submit your OSC Form 14.

Submit

OSC Form-14

OMB No. 3255-0005

File Type	application/pdf
File Title	USOSC Form14 071019.pdf
Author	spatel
File Modified	2019-07-12
File Created	2019-07-12