WHISTLEBLOWER DISCLOSURE FORM

WHISTLEBLOWER INFORMATION

Name *

Age

Sex

(2) Tel/Mobile number (Provide phone number that the Commission can reach you confidentially) *

Email

Postal address *

Address Line 1

City

State / Province / Region

Postal Code

Country

RESPONDENT(S) INFORMATION

(Body/Person who has committed, is committing or is about to commit the impropriety)

Name(s) of the person(s)/organisation(s) *

Tel/Mobile number

Email

Postal/Residential address

Address Line 1

City

State / Province / Region

Postal Code

Country

Is the person/body your employer? *

Yes
No

Is the person your fellow employee? *

Yes
No

Are you still in the same employment? *

Yes
No

Time and Place the impropriety took place, is taking place, or is about to take place

Period/Date of action *

//Date

Time

Region *

First

Middle

Last

Description/Nature of the impropriety and related action *

List any additional relevant information or supporting evidence

Attach any additional relevant information

(3) Did any other person witness the Commission of the impropriety? If Yes, answer question 4, if No, proceed to question 5

Yes
No

4. Provide the Commission with the following information on the witness, such as

(A) Full name of witness

(B) Phone number of witness

(C) Residential address of witness:

Address Line 1

City

State / Province / Region

(5) Have you made a disclosure of the same matter/impropriety to another body? If Yes, answer A and B , if No, proceed to question 6

Yes
No

A. Name the body to whom the disclosure was made

B. Name of person/body who committed or was about to commit the impropriety

(6) Have you ever made a whistleblower disclosure before ? If Yes proceed to A and B. If No proceed to submit

Yes
No

A. Name the body to whom the disclosure was made

B. Name of person/body who commited or was about to commit the impropriety

WHISTLEBLOWER DISCLOSURE FORM

WHISTLEBLOWER INFORMATION

RESPONDENT(S) INFORMATION

Time and Place the impropriety took place, is taking place, or is about to take place

PLEASE NOTE THAT YOU ARE TO REFRAIN FROM DISCUSSING THIS MATTER WITH ANOTHER PERSON/INSTITUTION.

PLEASE BE INFORMED THAT YOUR IDENTITY WOULD BE KEPT STRICTLY CONFIDENTIAL