Download:
pdf |
pdf(202) 254-3640 / (800) 572-2249
OMB Control No. 3255-0002
Exp. Date: 2/28/14
U.S. OFFICE OF SPECIAL COUNSEL
Form OSC-12
INFORMATION ABOUT FILING A WHISTLEBLOWER DISCLOSURE
WITH THE
OFFICE OF SPECIAL COUNSEL
IMPORTANT
Before filling out this Office of Special Counsel (OSC) Disclosure of Information form, please read the
following sections about limitations on OSC’s jurisdiction over whistleblower disclosures. Only the most
frequently occurring impediments to OSC jurisdiction are described. OSC may not have jurisdiction over you or
your disclosure for other reasons not discussed below.
COMPLETED DISCLOSURE FORMS CAN BE SENT TO OSC BY MAIL, AT: DISCLOSURE UNIT,
OFFICE OF SPECIAL COUNSEL, 1730 M STREET, N.W. (SUITE 218), WASHINGTON, DC 200364505. OR BY FAX: 202-254-3711
PLEASE KEEP A COPY OF DISCLOSURE MATERIALS PROVIDED TO OSC. REPRODUCTION
CHARGES UNDER THE FREEDOM OF INFORMATION ACT MAY APPLY TO REQUESTS
PROCESSED BY OSC FOR COPYING OF COPIES OF MATERIALS IN OSC FILES.
a violation of law, rule or regulation;
gross mismanagement;
gross waste of funds;
abuse of authority, or
substantial and specific danger to public health or safety.
OSC does not have authority to investigate the disclosures that it receives. The law provides that OSC will (a)
refer protected disclosures that establish a substantial likelihood of wrongdoing to the appropriate agency head,
and (b) require the agency head to conduct an investigation, and submit a written report on the findings of the
investigation to the Special Counsel.
If OSC finds no substantial likelihood that the information discloses one or more of the categories of wrongdoing,
the Special Counsel must: (a) inform the whistleblower of the reasons why the disclosure may not be acted on
further; and (b) direct the whistleblower to other offices available for receiving disclosures.
26&-85,6',&7,21
The Disclosure Unit has jurisdiction over federal employees, former federal employees, and applicants for federal
employment. It is important to note that a disclosure must be related to an event that occurred in connection with
the performance of an employee's duties and responsibilities. The Disclosure Unit has no jurisdiction over
disclosures filed by:
DISCLOSURE OF INFORMATION
Page ii
VISIT HTTP://WWW.OSC.GOV FOR MORE INFORMATION ABOUT
OSC JURISDICTION AND DISCLOSURE PROCEDURES
INFORMATION ABOUT FILING A WHISTLEBLOWER DISCLOSURE
WITH THE OSC (cont'd)
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.
U.S. OFFICE OF SPECIAL COUNSEL
(202) 254-3640 / (800) 572-2249
DISCLOSURE OF INFORMATION
(Please print legibly or type and complete all pertinent items. Enter "N/A" (Not Applicable) or
"Unknown" where appropriate.)
PART 1: BACKGROUND INFORMATION
1. Name of person seeking OSC action ("Complainant"): Mr. (
) Ms. (
) Mrs. (
) Miss (
)
2. Status:
Current Federal Employee
(
)
Applicant for Federal Employment
Former Federal Employee
(
)
Other (please specify):
3. Contact Information:
Home or mailing address:
Telephone number(s):
Fax number:
(
)
(Home)
(
)
(Office) Ext.
(
)
(Cell)
(
)
E-mail address:
4. Current position, title, series, and grade:
5. Agency Name:
6. Agency Address:
7. How did you first become aware that you could file a disclosure with OSC?
OSC Brochure ( )
OSC Poster ( )
OSC Speaker ( )
Agency Personnel Office (
)
Union (
)
Co-worker (
Other (please describe):
Date (approximate):
)
OSC Web Site (
)
News Story (
)
DISCLOSURE OF INFORMATION
Page 2
8. If you are filing this complaint as a legal or other representative of the person making a disclosure, please
supply the following information:
Name / title of filer:
Mr. ( )
Ms. ( )
Mrs. ( )
Miss ( )
9. Contact Information:
Home or mailing address:
Telephone number(s):
Fax number:
(
)
(Home)
(
)
(Office) Ext.
(
)
E-mail address:
PART 2: DETAILS OF YOUR DISCLOSURE
1. I know about the information I am disclosing here based on (check all that apply):
I have personal and/or direct knowledge of events or records involved ( )
Other employees have told me about events or records involved ( )
Other source(s) ( )
(please explain):
2. Please identify the U.S. government department or agency involved in your disclosure:
3. Please identify the organizational unit of the department or agency involved:
4. Address of the organizational unit:
5. Please identify the type of agency wrongdoing that you are alleging (check all that apply). If you check
"violation of law, rule, or regulation," please provide, if you can, the particular law, rule or regulation violated
(by name, subject, and/or citation).
Violation of law, rule, or regulation (
Gross mismanagement (
)
) (please specify):
Gross waste of funds (
Substantial and specific danger to public health (
Substantial and specific danger to public safety (
)
)
) Abuse of authority (
)
DISCLOSURE OF INFORMATION
Page 3
6. Please describe the agency wrongdoing that you are disclosing, indicating how the agency's actions fit within
the type(s) of wrongdoing that you checked in item 5. (Be as specific as possible about dates, locations and
the identities and positions of all persons named. Also, please attach any documents that might support your
disclosure. Continue on a separate sheet of paper if you need more space.)
DISCLOSURE OF INFORMATION
Page 4
PART 3: OTHER ACTIONS YOU ARE TAKING ON YOUR DISCLOSURE
1. I have previously disclosed (or am disclosing) the violations alleged here to (complete all that apply):
(
)
(
Inspector General of department / agency involved
Date:
/
/
) Other office of department / agency involved
(please specify):
Date:
/
/
(
) Department of Justice
Date:
/
/
(
) Other Executive Branch / department / agency
(please specify):
Date:
/
/
(
) General Accounting Office (GAO)
Date:
/
/
(
) Congress or congressional committee
(please specify member or committee):
Date:
/
/
(
) Press / media (newspaper, television, other)
(please specify):
Date:
/
/
2. If you disclosed the information reported here through any other channel described in question 1, above, what
is the current status of the matter?
PART 4: CONSENT, CERTIFICATION, AND SIGNATURE
Do you consent to the disclosure of your name to others outside the Office of Special Counsel if it becomes
necessary in taking further action on this matter?
I consent to disclosure of my name:
___________________________________________
Signature
_______________________
Date
I do not consent to disclosure of my name:
___________________________________________
Signature
_______________________
Date
DISCLOSURE OF INFORMATION
Page 5
I certify that all of the statements made in this complaint (including any continuation pages) are true, complete, and
correct to the best of my knowledge and belief. I understand that a false statement or concealment of a material
fact is a criminal offense punishable by a fine of up to $10,000, imprisonment for up to five years, or both. 18
U.S.C. § 1001.
__________________________________________________
Signature
___________________________
Date
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 on request. A summary of the routine uses appears below.
OSC may disclose information from its files in the following circumstances:
1. to disclose that an allegation of prohibited personnel practices or other prohibited activity has been filed;
2. to disclose information needed by the Office of Personnel Management (OPM) 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 anti-discrimination 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 (without identifying the complainant unless OSC has the
complainant's consent) as needed to conduct an investigation; obtain an agency investigation and report
on information disclosed to the OSC whistleblower disclosure channel; or to give notice of the status or
outcome of the 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;
DISCLOSURE OF INFORMATION
Page 6
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 needed by the Department of Justice for certain litigation purposes;
14. to provide information needed by courts or adjudicative bodies 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.
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 (at 5 U.S.C. § 1213) to receive disclosures from current or former federal employees, or
applicants for federal employment, alleging possible wrongdoing by federal agencies. The information will be used
by OSC to determine whether the facts establish that: (a) OSC has jurisdiction over the subject of the disclosure;
(b) there is a substantial likelihood that the facts indicate a violation of law, rule, or regulation; gross
mismanagement; a gross waste of funds; an abuse of authority; or a substantial and specific danger to public health
or safety; and (c) referral for investigation by the agency involved, or other appropriate action is warranted. The
reporting burden for this collection of information is estimated to be an average of one hour 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 U.S. Office
of Special Counsel, Legal Counsel and Policy Division, 1730 M Street, N.W. (Suite 201), Washington, DC 200364505. Use of this form to report disclosures of information is not mandatory. As indicated in part 4 of the form,
filers may request that OSC maintain their name in confidence.
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 2014-09-23 |