Whistleblowing Report Form

Who is make report*

I am a consumer or shareholder

I am an employee or ex-employee with concerns

Someone I know well witnessed wrongdoing at work

Someone I know well is committing wrongdoing at work

I want to report wrongdoing on behalf of my employer

Please provide a brief outline of the issue*

Please provide the names and/or designation of the people involved*

Please enter the time period of the issue in question

Is the alleged conduct still ongoing?*

Yes

No

Don't know

Please provide links to documents, photographs and any other proofs supporting your claim

What is the nature of your information?*

I heard/saw it myself

I heard people talking about it

Please provide names of superiors you have communicated this with beforehand, if any

Declaration of Policy Awareness*

I hereby confirm that I have read and understood the organization’s Whistleblowing Policy.

Declaration of Truthfulness*

I hereby declare that, to the best of my knowledge, the information I have provided is true and has been submitted voluntarily.

Acknowledgment of Use*

I understand and acknowledge that the information provided may be used during the investigation and reporting process, and that disclosure of my identity may be required by law, regulatory authorities, or judicial proceedings.

Author

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