Complaint of Reprisal Form

Does this apply to me?
The Public Interest Disclosure (Whistleblower Protection) Act applies to employees of government departments, offices of the Legislature, MLAs and their offices, Minister’s and their offices, the Premier and the Premier’s office, and public entities as prescribed in the Act's Regulations. If you believe you have been reprised against as a result of reporting a wrongdoing, seeking advice about reporting a wrongdoing, refusing to participate in a wrongdoing or doing anything in accordance with the Act, you may complete the form below to make a complaint to the Public Interest Commissioner. If you are unsure about any section of this form please call 1-855-641-8659 or E-mail: [email protected]

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General Contact Information
Last Name
Given Names
Title
Address
Street Address City Province Postal Code
Work Phone
Home Phone
Cell Phone
Email
Best Time to Contact
- Day
- Evening
- Weekend
Preferred Method of Contact
- Work Phone
- Home Phone
- Cell Phone
- Email
Name of Employer
Information about the Reprisal
Please provide a description of the reprisal(s) or threat(s) that have occurred or are occurring. Be sure to include all relevant dates, locations and names of individuals involved. Please attach any available supporting documents.
Reprisal Description*
Declaration
I believe that all the information provided is true to the best of my knowledge. I acknowledge that knowingly making a false or misleading statement is an offence pursuant to the Act.*
- I Do
Signature*
Date
MM slash DD slash YYYY
Please attach any available supporting documents.
Drop files here or

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Does this apply to me?

General Contact Information

Information about the Reprisal

Declaration