REQUEST TO CONDUCT A SPECIAL INVESTIGATION

Contact Information of Whistleblower

Title

Name of the person seeking action

Relationship to the University

Current employee

Applicant for employment

Former employee

Public member

Other…

Address

Address 2

City/Town

ZIP/Postal Code

Telephone number (home)

Telephone number (cellphone)

Telephone (Office Extention)

x

E-mail address

Current position

Staff or student number

Details of your relationship to the University

Department / Division

Campus

How did you become aware of the procedure to file a disclosure with Internal Audit?

Internal Audit web site

University web site

Personnel member

Public member

Union

Co-worker

News story

Other…

If you are filing this complaint as a legal or other representative of the person making a disclosure, please supply the following information

Title of filer

Name of filer

Address

Address 2

City/Town

ZIP/Postal Code

Telephone number

E-mail address

Details of your disclosure

I know about the information I am disclosing here based on (check all that apply):

I have personal and/or direct knowledge of events or records involved.

Other employees have told me about events or records involved.

Other…

Please identify the campus involved in your disclosure

Please identify the faculty / department involved

Address of the organisational unit involved

Please identify the type of agency wrongdoing that you are alleging (check all that apply).

Violation of rule, legal obligation, regulation, statutes or legislation

Financial maladministration or impropriety or fraud

Substantial and specific dangers to health & safety or the environmen

Criminal activity

Improper conduct or unethical behaviour

Gross waste of funds

Abuse of authority

Attempts to conceal any of these

Other

Please provide, where possible, the applicable law, rule or regulation violated (by name, subject, and/or citation)

Please specify other

Please describe the details of your disclosure (kindly provide specifics as best as possible. Include dates, locations, identities and positions of persons mentioned.

Where possible, attach supporting documents.

Upload requirements

If you disclosed the information reported here through any other channel, please give details and what is the current status of the matter?

Certification

I certify that all of the statements made in this complaint (including any continuation pages) are true and correct to the best of my knowledge and belief.

Date

INFORMATION DISCLOSURE