Complaint/Whistleblowing Form

Complaint/Whistleblowing Form

Your safety and confidentiality are our priority. This form allows you to report concerns about unethical, illegal, or inappropriate conduct within our organization.

Reporter Information (Optional)
Note: You may choose to remain anonymous. However, providing contact details may help us follow up for further information.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Prefered method of contact

EmailPhoneIn personOther

Details of the Concern
Please enter the date(s) the misconduct occurred. If you remember the time(s), you can enter.
Please provide details of person(s) involved (if known):
Description of the misconduct (Please be detailed):*
Relationship to the complainant*

SubordinateSupervisorCo-workerOther
Does misconduct continue?*

YesNo

Supporting Evidence
Please describe any evidence you have (documents, emails, photos, etc.)
Please provide any related files (Photos, documents, voice records, etc.)

Cancelof
Have you ever complained or provided information verbally and/or in writing about sexual harassment?*

YesNo
Please give more detail

Witnesses (if any)
If there are other involved parties and witnesses), Please write here.
Do you have a legal counselor and would like us to work with them?

YesNo
Please give your legal counselor's contact information

Desire Outcome
What action would you like to see taken?*

Confidentiality & Protection Assurance
We assure you that all reports will be treated with the utmost confidentiality and without any retaliation against the reporter.
Please verify that you are human*
Should be Empty: