Disclosure of Wrongdoing Form | Alberta’s Public Interest Commissioner

Does this apply to me?

The Public Interest Disclosure (Whistleblower Protection) Act applies to employees of government departments, offices of the Legislature and public entities as prescribed in the Act's regulations.

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Use this form to report a wrongdoing. If you are unsure about any section of this form, please call 1.855.641.8659 or email info@pic.alberta.ca.

"*" indicates required fields

Have you made a complaint to your designated officer?*

The designated officer is the senior official delegated the responsibility of receiving, investigating, and reporting on internal disclosures of wrongdoing made by employees in accordance with the Act.

Yes

Under which circumstance are you making the disclosure to the Public Interest Commissioner?*

To advise the Commissioner that a disclosure was made to the designated officer for the purpose of commencing an investigation

An investigation has not been completed by the designated officer in accordance with my organization’s procedures

The matter has not been resolved within the time periods established by my organization’s procedures

The investigation has been completed and a final decision has been issued; however, I am dissatisfied with the decision

A reprisal has been taken or directed against me

Under the Public Interest Disclosure (Whistleblower Protection) Act, employees have the choice of reporting wrongdoing to their designated officer or to the Public Interest Commissioner. If an employee chooses to make a disclosure to their designated officer, they have the right to return the matter to the Public Interest Commissioner if they are dissatisfied with the decision. In certain circumstances, it may be advantageous to report the wrongdoing to a designated officer as they are more familiar with the organization. In circumstances where the alleged wrongdoing relates to senior leaders of the organization, it is recommended that the disclosure be made to the Public Interest Commissioner. If you are uncertain who your designated officer is, or would like advice prior to completing this form, please contact the office of the Public Interest Commissioner.

Would you like to make this disclosure to your designated officer, or to the Public Interest Commissioner?

I’d like to make this disclosure of wrongdoing to my designated officer

I’d like to make this disclosure of wrongdoing to the Public Interest Commissioner

Disclosure Details

Which of the below categories does the wrongdoing apply to?*

Contravention of an act or a regulation (contravention of a law).

An act or omission that creates a substantial and specific danger to the life, health or safety of individuals.

An act or omission that creates a substantial and specific danger to the environment.

Gross mismanagement of public funds or a public asset.

Gross mismanagement of the delivery of a public service.

Gross mismanagement of employees – by a pattern of behavior or conduct of a systemic nature that indicates a problem in the culture of the organization relating to bullying, harassment or intimidation.

Counselling an individual to commit a wrongdoing mentioned above.

If none of the above, the Public Interest Disclosure Act does not apply. Consider internal department resolution mechanisms.

Use this area to provide information about the wrongdoing and the person(s)/organizations alleged to have committed the wrongdoing (if known).

Describe the wrongdoing:*

When did the wrongdoing occur?*

Provide the name of the department, office or public entity where the wrongdoing occurred, and if applicable, the specific division or business unit:*

Provide the names and titles of the individuals responsible for the wrongdoing:*

Provide the names and contact information for witnesses who may have information (if known):

Provide information on any other authority you’ve reported this matter to, and the outcome:*

Please attach any available supporting documents.

Drop files here or

Accepted file types: jpg, jpeg, png, doc, docx, txt, pdf, Max. file size: 10 MB.

- Individual files are limited to 10MB.
- If your file exceeds that amount, upload a zip folder or contact our office for further instructions.
- Retain your copy of files you submit.

General Contact Information

While anonymous complaints may be accepted, you are encouraged to include your name and contact information. The Commissioner or your designated officer may not be able to act on a disclosure of wrongdoing if inadequate particulars are provided, and if there is no way to obtain further details from you. For more information about the advantages and disadvantages of making an anonymous complaint, contact our office.

Last Name

Given Names

Personal Pronouns

Cell Phone

Other Phone

Preferred Method of Contact

Phone

Name of Your Organization

Branch/Unit/Department (if applicable)

Your Title

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