Form OSC-11: Complaint of Prohibited Personnel Practice / Other Prohibited Activity

Form OSC-11 (09/12)

OMB Control No. 3255-0002

COMPLAINTS ALLEGING REPRISAL FOR WHISTLEBLOWING
ADDITIONAL DISCLOSURES AND PERSONNEL ACTIONS

Date Received by OSC:____________________________

OSC Attorney, Investigator, or Complaint Examiner:

________________________________________

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

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

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

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

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

d. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR, OR WAS THREATENED BECAUSE OF THE DISCLOSURE?

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

Date Received by OSC:____________________________

OSC Attorney, Investigator, or Complaint Examiner:

________________________________________

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

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

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

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

.d. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR, OR WAS THREATENED BECAUSE OF THE DISCLOSURE?

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

KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

Form OSC-11 (09/12)

OMB Control No. 3255-0002

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

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

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

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

d. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR, OR WAS THREATENED BECAUSE OF THE DISCLOSURE?

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

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

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

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

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

.d. WHAT PERSONNEL ACTION OCCURRED, FAILED TO OCCUR, OR WAS THREATENED BECAUSE OF THE DISCLOSURE?

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

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

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