Whistleblower Report Form

WHISTLEBLOWER REPORT FORM

Please provide the following details for any suspected serious misconduct or any breach or suspected breach of law or regulation that may adversely impact Achēv. Please note that you may be called upon to assist in the investigation if required.

Note: Please follow the guidelines as laid out in the Whistleblower Policy. You should share your question(s), concern(s), suggestion(s) or complaint(s) with someone who can address them properly. In most cases, you should report in strict confidence to ACHĒV’s Chief Executive Officer (CEO). However, if you are not comfortable sending your concern(s) to the CEO or you are not satisfied with the response you received, you are encouraged to report to the Chair or ViceChair of the Board of Directors. This form is compliant with Achēv’s Privacy and Confidentiality Policy.

To leave a voicemail on the Whistleblower inbox please call: (289) 863 8120

REPORT DESTINATION

Please choose recipient: *

CEO
Vice Chair of the Board of Directors
Chair of the Board of Directors

REPORTER’S CONTACT INFORMATION

Name *

First

Last

Department (or name of external organization) *

Email *

Please enter your email, so we can follow up with you.

IMPLICATED PERSON'S INFORMATION

Name *

First

Last

Department (or name of external organization) *

Email *

WITNESS INFORMATION (if any)

Name

First

Last

Department (or name of external organization)

COMPLAINT: Briefly describe the misconduct / improper activity and how you know about it. Specify what, who, when, where and how. If there is more than one allegation, number each allegation.

Please provide details about the suspected wrongdoing. (attach separate file(s) if needed) *

Please provide the names of all the persons involved with the situation, including any other persons aware of the suspected wrongdoing *

Please provide the relevant dates and time periods related to the suspected wrongdoing identified in as much detail as possible. *

Where did it happen? *

Is there any evidence that you could provide us?

Are there any other parties involved other than the suspect stated above?

Do you have any other details or information which would assist us in the investigation?

Any other comments?

Please include any relevant attachments

Click or drag files to this area to upload. You can upload up to 5 files.

Date / Time *

Date

Time

Would you have preferred to call a toll free number and leave a voice message?