Form Osc 11 – Fill Out and Use This PDF

U.S. OFFICE OF SPECIAL COUNSEL

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

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE

OR

OTHER PROHIBITED ACTIVITY

(Please print legibly or type and complete all pertinent items. Enter "N/A" (Not Applicable) or "Unknown" where appropriate. (If more space is
needed, use Continuation Sheet at page 12.)
PART 1: PROHIBITED PERSONNEL PRACTICES PROHIBITED ACTIVITY (GENERAL)
1. Name of person seeking OSC action ("Complainant"):	Mr. ( ) Ms. ( ) Mrs. ( ) Miss ( )

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

2.Position, title, series, and grade:

3.Agency name:

4.Agency Address:

5.Home or mailing address:

6. Contact information:Telephone number(s): (				)					(Home)
		(			)				(Office) Ext.
	Fax number:	(
						)
	E-mail address:

7. If you are filing this complaint as a legal or other representative of the Complainant, please supply the following information:

Name and title of filer:				Mr.( )	Ms.( )	Mrs.(	)	Miss( )
Address:
Telephone number(s): (						(Home)
			)
(						(Office)	Ext.
			)
Fax number: (
			)

		E-mail address:
8.	Are you (or is the Complainant, if you are filing as a representative) covered by a collective bargaining agreement? (Check one.)
		(	)Yes		( ) No	(	) I don'tknow
9.	How did you first become aware that you could file a complaint with OSC?
	(	) OSC Web site	(		) OSC Speaker	(	) OSC Brochure	(	) OSC Poster
	(	) NewsStory	(		) AgencyPersonnel Office	(	) Union	(	) Co-worker
	(	) Other (please describe):

Date (approximate):

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY

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PART 2: REPRISAL FOR WHISTLEBLOWING

This part of the form is solely for use by persons alleging reprisal for whistleblowing (that is, persons who believe that personnel actions were taken, not taken, or threatened because of a whistleblower disclosure). Please read the introductory material before answering the questions that follow. If more space is needed, use the continuation sheet at page 12.

Complainants not alleging reprisal for whistleblowing should proceed to Part 3 (“Consent to Certain Disclosures of Information”), at page 9.

Reprisal for Whistleblowing Allegations

As a general rule, it is a prohibited personnel practice to take or fail to take, or threaten to take or fail to take, a personnel action because of a protected disclosure of certain types of information by a Federal employee, former employee, or applicant for Federal employment. 5 U.S.C. § 2302(b)(8).

Legal Elements of a Violation

By law, certain elements must be present before OSC can establish that a legal violation of law has occurred. Two of the required elements that must be established are: (1) that a whistleblower disclosure was made; and (2) that an agency took, failed to take, or threatened to take or fail to take a personnel action because of the whistleblower disclosure. Your description of these elements will help OSC's investigation of your allegation(s).

Protected Disclosures

A disclosure of information is a protected whistleblower disclosure if a Federal employee, former employee, or applicant for Federal employment discloses information which he or she reasonably believes evidences: (a) a violation of any law, rule, or regulation; (b) gross mismanagement; (c) a gross waste of funds; (d) abuse of authority; or (e) a substantial and specific danger to public health or safety.

Covered Personnel Actions

The law prohibiting reprisal for whistleblowing requires proof that one or more of the following personnel actions occurred, or failed to occur, because of a protected disclosure:

(1)an appointment;

(2)a promotion;

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

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY

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(4)a detail, transfer, or reassignment;

(5)a reinstatement;

(6)a restoration;

(7)a reemployment;

(8)a decision about pay, benefits, or awards, concerning education or training if the education

or training may reasonably be expected to lead to an appointment, promotion, performance evaluation, or other action described in 5 U.S.C. § 2302(a)(2);

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

(10)a decision to order psychiatric testing or examination; or

(11)any other significant change in duties, responsibilities, or working conditions.

Reporting Your Allegation(s)

In the section that starts below (pages 6-8), provide the information requested about all disclosures that you believe led to reprisal by the agency involved. If more space is needed, use extra copies of page 6-8, or the Continuation Sheet at page 12. If any of the disclosures were in writing, please provide a copy of the disclosure with your complaint.

IT IS IMPORTANT THAT YOU LIST ALL DISCLOSURES AND PERSONNEL ACTIONS INVOLVED IN YOUR COMPLAINT. This is because: (1) failure to list any disclosure or personnel action may delay the processing of your complaint by OSC; and (2) a comprehensive listing will avoid disputes in any later Individual Right of Action (IRA) appeal that you may file with the Merit Systems Protection Board (MSPB) about its jurisdiction to hear case.

Additional allegations of reprisal for whistleblowing may be added to this complaint while it is pending at OSC. Submission of any such additional allegations to OSC in writing will help you if you decide to file any later IRA appeal with the MSPB. Form OSC-11a is available for that purpose at OSC's web site, under "Forms."

Appeal to the Merit Systems Protection Board (MSPB)

If OSC fails to complete its review of your whistleblower reprisal allegation within 120 days after it receives your complaint, or if it closes your complaint at any time without seeking corrective action on your behalf, you have the right to file IRA appeal with the MSPB. 5 U.S.C. § 1214(a)(3).

Recordkeeping

To establish its jurisdiction over any later IRA appeal that you may file, the MSPB will require you to show that the appeal relates to the same whistleblower disclosure(s) and personnel action(s) involved in your complaint to OSC. A copy of the whistleblower reprisal allegations in your complaint, any supporting documentation about those allegations that you sent with the complaint, and any additional allegation of reprisal that you submitted in writing to OSC while the complaint was pending, will serve as proof in any IRA of the disclosure(s) and personnel action(s) involved in your OSC complaint. IT IS IMPORTANT, THEREFORE, THAT YOU MAKE AND KEEP COPIES OF ALL THESE DOCUMENT FOR YOUR RECORDS.

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY

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MUST BE COMPLETED FOR ALL DISCLOSURES REPORTED IN THIS COMPLAINT

A. WHAT INFORMATION WAS DISCLOSED? (DESCRIBE WHISTLEBLOWER DISCLOSURE).

1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

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

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that apply):

( ) VIOLATION OF LAW, RULE, OR REGULATION ( ) GROSS MISMANAGEMENT

( ) GROSS WASTE OF FUNDS ( ) ABUSE OF AUTHORITY

( ) SUBSTANTIAL AND SPECIFIC DANGER TO PUBLICHEALTH OR SAFETY

( ) NONE OF THE ABOVE

4. WHAT PERSONNEL ACTION(S) OCCURRED, FAILED TO OCCUR, OR WAS THREATENED BECAUSE OF THE DISCLOSURE? (List all applicable personnel action numbers from pages 4-5).

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

B. WHAT INFORMATION WAS DISCLOSED?

(DESCRIBE NEXT WHISTLEBLOWER DISCLOSURE).

1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

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

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that apply):

(							)		VIOLATION OF LAW, RULE, OR REGULATION
(							)		GROSS MISMANAGEMENT
(								)	GROSS WASTE OF FUNDS
(								)	ABUSE OF AUTHORITY
(								) SUBSTANTIAL AND SPECIFIC DANGER TO
									PUBLICHEALTH OR SAFETY
(						)			NONE OF THE ABOVE

4. WHAT PERSONNEL ACTION(S) OCCURRED, FAILED TO OCCUR, OR WAS THREATENED BECAUSE OF THE DISCLOSURE? (List all applicable personnel action numbers from pages 4-5).

5. WHEN DID PERSONNEL ACTION(S) OR THREAT(S) OCCUR?

(MO/DA/YR)

KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY

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MUST BE COMPLETEDFOR ALL DISCLOSURESREPORTEDIN THIS COMPLAINT

C. WHAT INFORMATION WAS DISCLOSED? (DESCRIBE NEXT WHISTLEBLOWER DISCLOSURE).

1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

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

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that apply):

( ) VIOLATION OF LAW, RULE, OR REGULATION

(			)					GROSS MISMANAGEMENT
(					)			GROSS WASTE OF FUNDS
(						)		ABUSE OF AUTHORITY
(							) SUBSTANTIAL AND SPECIFIC DANGER TO
								PUBLICHEALTH OR SAFETY
(				)				NONE OF THE ABOVE

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

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

D. WHAT INFORMATION WAS DISCLOSED?

(DESCRIBE NEXT WHISTLEBLOWER DISCLOSURE).

1. WHEN WAS THE DISCLOSURE MADE? (MO/DA/YR)

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

3. DISCLOSURE OF INFORMATION EVIDENCED (check all that

apply):

(

)

VIOLATION OF LAW, RULE, OR REGULATION

(

)

GROSS MISMANAGEMENT

(

)

GROSS WASTE OF FUNDS

(

)

ABUSE OF AUTHORITY

(

) SUBSTANTIAL AND SPECIFIC DANGER TO

PUBLICHEALTH OR SAFETY

(

)

NONE OF THE ABOVE

4. WHAT PERSONNEL ACTION(S) OCCURRED, FAILED TO OCCUR, OR

WAS

THREATENED BECAUSE OF THE DISCLOSURE? (List all

applicable personnel action numbers from pages 4-5).

5. WHEN DID PERSONNEL ACTION(S) OR THREAT(S) OCCUR?

(MO/DA/YR)

KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY

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MUST BE COMPLETED FOR ALL DISCLOSURES INCLUDED IN THIS COMPLAINT

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

Disclosure:

A ( )

B ( )

C ( )

D ( )

Name: Address:

Telephone number: (		)		Ext.

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

5. What action would you like OSC to take in this matter (that is, what remedy are you asking for)?

KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY

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PART 3: CONSENT TO CERTAIN DISCLOSURES OF INFORMATION

OSC asks everyone who files a complaint alleging a possible prohibited personnel practice or other prohibited activity to select one of three Consent Statements shown below. IF YOU DO NOT SELECT ONE OF THE THREE CONSENT STATEMENTS BELOW, OSC WILL ASSUME THAT YOU HAVE SELECTED CONSENT STATEMENT 1. Please: (a) select and sign (or check, if filing electronically) one of the Consent Statements below; and (b) keep a copy of the Consent Statement you select (as well as a copy of all documents that you send to OSC) for your own records.

If you initially select a Consent Statement that restricts OSC's use of information, you may later select a less restrictive Consent Statement. If your selection of Consent Statement 2 or 3 prevents OSC from being able to conduct an investigation, an OSC representative will contact you, explain the circumstances, and provide you with an opportunity to select a less restrictive Consent Statement.

You should be aware that the Privacy Act allows information in OSC case files to be used or disclosed for certain purposes, regardless of which Consent Statement you sign. See 5 U.S.C. § 552a(b). Information about certain circumstances under which OSC can use or disclose information under the Privacy Act appears on the next page.

(Please sign one)

Consent Statement 1

I consent to OSC’s communication with the agency involved in my complaint. I agree to allow OSC to disclose my identity as the complainant, and information from or about me, to the agency if OSC decides that such disclosure is needed to investigate the allegation(s) in my complaint (for example, to request information from the agency, or seek a possible resolution through mediation or corrective action). I understand that regardless of the Consent Statement I choose, OSC may disclose information from my complaint file when permitted by the Privacy Act (including circumstances summarized in Part 5, below).

_________________________________________________________		_______________________________
Complainant's Signature for Consent Statement 1		Date Signed

Consent Statement 2

I consent to OSC’s communication with the agency involved in my complaint, but I do not agree to allow OSC to disclose my identity as the complainant to that agency. I agree to allow OSC to disclose only information from or about me, without disclosing my name or other identifying information, if OSC decides that such disclosure is needed to investigate the allegation(s) in my complaint (for example, to request information from the agency, or seek a possible resolution through mediation or corrective action). I understand that in some circumstances (for example, if I am complaining about my failure to receive a promotion), OSC could not maintain my anonymity while communicating with the agency involved about a specific personnel action. In such cases, I understand that this request for confidentiality might prevent OSC from taking further action on my complaint. I also understand that regardless of the Consent Statement I choose, OSC may disclose information from my complaint file when permitted by the Privacy Act (including circumstances summarized in Part 5, below).

_________________________________________________________		_______________________________
Complainant's Signature for Consent Statement 2		Date Signed

Consent Statement 3

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

_________________________________________________________		_______________________________
Complainant's Signature for Consent Statement 3	Date Signed

COMPLAINT OF POSSIBLE PROHIBITED PERSONNEL PRACTICE OR OTHER PROHIBITED ACTIVITY

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PART 4: CERTIFICATION AND SIGNATURE

Icertify that all of the statementsmade in this complaint (including any continuation pages) are true, complete, and correct to the best of my knowledge and belief. I understandthat a false statement or concealment of a material fact is a criminal offense punishable by a fine of up to $250,000, imprisonmentfor up to five years, or both. 18 U.S.C. § 1001.

________________________________________________________		_________________________________
Signature		Date Signed

PART 5: PRIVACY ACT / PAPERWORK REDUCTION ACT STATEMENTS

Routine Uses. Limited disclosure of information from OSC files is needed to fulfill OSC's investigative, prosecutorial, and related responsibilities. OSC has described 18 routine uses for information in its files in the Federal Register (F.R.), at 66 F.R. 36611 (July 12, 2001), and 66 F.R. 51095 (October 5, 2001). A copy of the routine uses is available from OSC upon request. A summary of the routine uses appears below.

OSCmay disclose informationfrom its files in the followingcircumstances:

1.to disclose that an allegation of prohibited personnel practices or other prohibited activity has been filed;

2.to disclose information to the Office of Personnel Management (OPM) as needed for inquiries involving civil service laws, rules or regulations, or to obtain an advisory opinion;

3.to disclose information about allegations or complaints of discrimination to entities concerned with enforcement of antidiscrimination laws;

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

5.to the involved agency, MSPB, OPM, or the President when OSC has reason to believe that a prohibited personnel practice has occurred, exists, or is to be taken;

6.to disclose information to Congress in OSC's annual report;

7.to disclose information to third parties as needed to conduct an investigation; obtain an agency investigation and report on information disclosed to OSC's whistleblower disclosure channel; or to give notice of the status or outcome of an investigation;

8.to disclose information as needed to obtain information about hiring or retention of an employee; issuance of a security clearance; conduct of a security or suitability investigation; award of a contract; or issuance of a license, grant, or other benefit;

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

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10.to provide information from an individual's record to a congressional office acting pursuant to the individual's request;

11.to furnish information to the National Archives and Records Administration for records management purposes;

12.to produce summary statistics and work force or other studies;

13.to provide information to the Department of Justice as needed for certain litigation purposes;

14.to provide information to courts or adjudicative bodies as needed for certain litigation purposes;

15.to disclose information to the MSPB as needed in special studies authorized by law;

16.for coordination with an agency's Office of Inspector General or comparable entity, to facilitate the coordination and conduct of investigations and review of allegations;

17.to news media or the public in certain circumstances (except when the Special Counsel determines that disclosure in a particular case would be an unwarranted invasion of personal privacy); and

18.to the Department of Labor and others as needed to implement the Uniformed Services Employment and Reemployment Rights Act of 1994, and the Veterans' Employment Opportunities Act of 1998.

If OSC officials believe that disclosure may be appropriate in a situation not covered by one of OSC's routine uses, or one of the 11 other exceptions to the Privacy Act's general prohibition on disclosure, OSC will seek written authorization from the complainant permitting the disclosure.

Purposes, Burdens, and Other Information. An agency may not conduct or sponsor a collection of information, and persons may not be required to respond to a collection of information, unless it: (a) has been approved by OMB, and (b) displays a currently valid OMB control number. The information in this form is collected pursuant to OSC's legal responsibility to investigate: (a) allegations of prohibited personnel practices, to the extent necessary to determine whether there are reasonable grounds to believe that a prohibited personnel practice has occurred, exists, or is to be taken (5 U.S.C. § 1214); and

(b)other allegations of prohibited activity (5 U.S.C. § 1216). The information will be reviewed by OSC to determine whether the facts establish its jurisdiction over the subject of the complaint, and whether further investigation and corrective or disciplinary action is warranted. The reporting burden for this collection of information is estimated to be an average of one hour and 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the form. Please send any comments about this burden estimate, and suggestions for reducing the burden, to the Office of Special Counsel, Legal Counsel and Policy Division, 1730 M Street, N.W. (Suite 218), Washington, DC 20036-4505. Use of this form to file a complaint alleging a prohibited personnel practice or other prohibited activity is required; use of this to file a complaint alleging only a Hatch Act violation is not required. 5 C.F.R. § 1800.1(d), as amended. As stated in Part 3 of this form, complainants may request that OSC maintain their name, and information provided by them, in confidence.