Whistleblower Case Submission Questionnaire

Please use this questionnaire to submit your concerns regarding potential violations of company policies, ethical standards, or legal regulations. Your submission will be handled confidentially, and you will be protected from retaliation in accordance with our Whistleblower Policy.

You may submit anonymously. If you prefer to remain anonymous, choose "Do not contact me" below and do not enter contact details. Attachments are stored anonymously and cannot be linked to your identity.

* Indicates required question

Your Contact Information (Optional)

Full Name Email Phone

Preferred Method of Contact *

Email Phone Do not contact me (remains confidential or anonymous)

Details of the Concern

What type of concern are you reporting? (Select all that apply) *

Fraud or financial misconduct Violation of laws or regulations Conflict of interest Discrimination or harassment Unethical business practices (bribery, corruption, etc.) Workplace safety violations Environmental violation Violation of company policies Other

Date the incident occurred or was first noticed *

More details related to timeframe/period can be added in the description area.

Location (if relevant)

Describe the issue in detail *

Are there any witnesses to the incident(s)? *

If Yes, please provide their names and contact information in the description area (optional).

Yes No

Evidence and Documentation

Do you have any documents, emails, screenshots, or other evidence to support your claim? *

Yes No

Have you previously reported this issue to anyone within the company? *

If yes, please provide details on who you reported it to, when, and what actions (if any) were taken:

Yes No

Confirmation and Acknowledgment *

By submitting this form, I confirm that the information provided is true to the best of my knowledge, and I understand that providing false or malicious information may result in disciplinary action. I acknowledge that I will be protected against retaliation under the organization's Whistleblower Policy.

I acknowledge