Public Interest Disclosure Report Form

Are you a current employee of the school district?*

Answer Required

Yes

Were you an employee of the school district when the alleged wrongdoing occurred or was discovered?*

Answer Required

Yes

Please enter your contact information below so that we can communicate with you about your disclosure. Your identity and contact information will be kept in confidence and may be shared with investigators to allow them to communicate with you.

While anonymous disclosures may be accepted under the Public Interest Disclosure Act, we may not be able to investigate if we are unable to contact you to confirm that you are a current or former employee or to obtain further details, evidence or clarification about your disclosure.

First Name:

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Last Name:

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Email:

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Address:

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Mobile Phone:

Number Required

Additional Instructions:

e.g. How would you prefer to be contacted? May we leave messages for you?

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A report may be made under the Public Interest Disclosure Act for any of the following categories of wrongdoing. If your report does not fall within one of these categories, you may wish to consider whether your report falls under another policy or procedure of the school district. Please check any that apply:

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serious act or omission that, if proven, would constitute an offence under an enactment of British Columbia or Canada;

an act or omission that creates a substantial and specific danger to the life, health or safety of persons, or to the environment, other than a danger that is inherent in the performance of an employee's duties or functions;

a serious misuse of public funds or public assets;

gross or systemic mismanagement

knowingly directing or counselling a person to commit a wrongdoing described above.

In the space below, please describe the alleged wrongdoing and the person(s) alleged to have committed the wrongdoing. Please provide as much detail as you are able, including a description of the wrongdoing and any relevant background, the names of those responsible, when and where the wrongdoing occurred, names of people who witnessed the wrongdoing, and if available, any law or legislation that has been breached.

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Have you previously reported the wrongdoing to the school district?

Answer Required

Yes

If yes, please indicate who the report was made to and any actions taken:

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Please describe any other steps or action that you or others have taken to address, report or prevent the reported wrongdoing.

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Do you know of any other organizations that are investigating the reported wrongdoing or whether other complaints or claims about the wrongdoing have been filed (e.g. court filings, grievance, human rights complaint, privacy complaint, police investigation, etc.). Please explain:

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Please fix the highlighted areas below before submitting.

Public Interest Disclosure Report Form