Registration Form

• Issuer: U.S. Office of Special Counsel
• Section: U.S. Office of Special Counsel

U.S. Office of Special Counsel

1730 M Street NW, Suite 218

Washington, DC 20036-4505

(202)804-7163certification@osc.gov

U.S. Office of Special Counsel’s

Certification Program RegistrationForm

The U.S. Office of Special Counsel's (OSC) Certification Program allows federalagencies tomeet the

statutory obligations of 5 U.S.C. § 2302(c), the Dr. Chris Kirkpatrick Whistleblower Protection Act, and

the Office of Special Counsel Reauthorization Act of 2017. In addition to the existingrequirements of the

program, these statutes require agency heads toensure that their employeesreceive yearly information

about whistleblower protection laws and to provide annual supervisory training on how to respond to

complaints involving whistleblower protections. If you have any questions about completing this form or

OSC’s Certification Program, please contactOSC’s Diversity, Outreach, and Training Unit at

certification@osc.govor (202) 804-7163.

Pleaserefertoour Certification Process Instructions.

General Information

RegisteringAgency or Office:

Agency and OIG ☐

Agency ☐

OIG☐

Component (please indicate parent agency)

Contact Information

Please provide the contact information for the official responsible forimplementing OSC's

Certification Program (the individual’s name and phone number will be placed on OSC’s

website asthe point of contact once the agency is certified).

Name:

Title:

Email:

Phone:

Address (to send certificate):