Form OSC-11a Complaints Alleging Reprisal for Whistleblowing: Additional Disclosures and Personnel Actions

Form OSC-11a or the "Complaints Alleging Reprisal For Whistleblowing: Additional Disclosures And Personnel Actions" is a form issued by the U.S. Office of Special Counsel.

The form was last revised in September 1, 2012 and is available for digital filing. Download an up-to-date fillable Form OSC-11a in PDF-format down below or look it up on the U.S. Office of Special Counsel Forms website.

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Form OSC-11a (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):
(
)
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)
KEEP A COPY OF THIS PAGE FOR YOUR RECORDS
Form OSC-11a (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):
(
)
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)
KEEP A COPY OF THIS PAGE FOR YOUR RECORDS

Download Form OSC-11a Complaints Alleging Reprisal for Whistleblowing: Additional Disclosures and Personnel Actions

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