Whistleblower Complaint Intake Form

Intake form for employees or third parties to report suspected misconduct, with options for anonymous submission, witness details, confidentiality concerns, and supporting evidence.

Reporting Options and Consent

• How would you like to submit this report?
• Consent and disclosure acknowledgement
  I understand this form may collect limited PII if I choose to provide it, and that the information will be used only for compliance review, investigation, and audit trail purposes.
• Do you have confidentiality or retaliation concerns?
• Please describe your confidentiality or retaliation concerns
  Share only what is necessary. Do not include sensitive personal data unless it is directly relevant.

Reporter Information

• Your name
• Your relationship to the organization
• Email address
  Provide an email only if you want to be contacted for follow-up.
• Phone number
  Optional contact number for follow-up.

Incident Details

• Date of incident or first observed issue
  If the issue occurred over time, provide the earliest known date.
• Location or department involved
• Type of concern
• Describe what happened
  Include who was involved, what occurred, when it happened, and why you believe it is misconduct.
• Is this an ongoing issue?

People and Witnesses

• Person or team involved
  If you do not know a name, provide a role, title, or team.
• Were there any witnesses?
• Witness details
  Add only the witness information you know and are authorized to share.

Supporting Evidence and Follow-Up

• What supporting evidence do you have?
• Upload supporting evidence
  Upload only files that are relevant to the report and permitted by policy.
• How should we follow up?
• Anything else we should know?