Whistleblowing Form

The more information and details you provide, the better an investigation can be conducted. Please give a detailed description of the exact event, what you saw, heard or witnessed. When reporting an incident, please be as specific and objective as possible and do not include bias information.

a. Describe the incident

b. Were you personally involved in the incident? *

Yes

No

How did you become aware of the incident? *

c. Specify the name(s) of the person(s) involved in the incident *

I prefer not to say

d. What is the relation to the company of the person(s) involved in the incident? *

e. If other, please specify the relation to the company: *

Specify the timeframe in which the incident happened (please enter a specific date or time range).

From *

Until *

The incident is still going on today.

f. How long have you been aware of the incident? *

g. Where did the incident take place? (specify the exact location/address) *

h. Did anyone else witness the incident? *

No

Yes

Who else witnessed the incident? *

i. Is anyone else aware of the incident? *

No

Yes

Who else knows about the incident?

j. If you have any supporting documents, please attach them here: