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:

________________________________________


(DESCRIBE WHISTLEBLOWER DISCLOSURE.
 


()   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


Date Received by OSC:____________________________ OSC Attorney, Investigator, or Complaint Examiner:

________________________________________


(DESCRIBE NEXT WHISTLEBLOWER DISCLOSURE.
 


()   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



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