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: firstname.lastname@example.org * indicates a required field.General Contact InformationLast NameGiven NamesTitleAddress Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Work PhoneHome PhoneCell PhoneEmail Best Time to Contact Day Evening Weekend Preferred Method of Contact Work Phone Home Phone Cell Phone Email Name of EmployerInformation about the ReprisalPlease 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*DeclarationI 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*Please attach any available supporting documents. Drop files here or Accepted file types: jpg, jpeg, png, doc, docx, txt, pdf. - Individual files are limited to 5 MB. - Maximum of 3 file uploads. - Retain your copy of files you submit. - Acceptable formats include: jpeg, png, doc, docx, txt, pdf.Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms.