WHISTLEBLOWER DISCLOSURE FORM

Name *

Age

Sex

Tel/Mobile Number *

Email

Postal/Residential 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

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 of action (Date(s)) *

//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

Did anyone witness the commission of the impropriety? [Yes/No] If yes,

Yes
No

Full name of Witness

Phone number

Contact/Address of Witness:

Address Line 1

City

State / Province / Region

Have you made a disclosure of the same matter/impropriety on a previous occasion to another body? [Yes/No]

Yes
No

a. If yes, name the body to whom the disclosure was made *

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

Have you made a disclosure of some other matter on a previous occasion to another body? [Yes/No]

Yes
No

a. If yes, name the body to whom the disclosure was made *

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

PLEASE BE INFORMED THAT YOUR IDENTITY WOULD BE KEPT STRICTLY CONFIDENTIAL

PLEASE BE ASSURED THAT YOUR IDENTITY AND THE INFORMATION THAT YOU GIVE WOULD BE KEPT CONFIDENTIAL IN ACCORDANCE WITH THE WHISTLEBLOWER ACT, 2006 (ACT 720)

WHISTLEBLOWER DISCLOSURE FORM

RESPONDENT(S) INFORMATION

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