Protected disclosure form

Yes, I have read this information (required)

Information about serious wrongdoing

Name of organisation/person conducting a business or undertaking (PCBU) where the wrongdoing happened or is happening (required)

Address where the serious wrongdoing happened or is happening (required)

Describe the serious wrongdoing, including when it happened (date and time if known) and if it is still happening (required)

Use specific examples where you can

Describe how you became aware of the serious wrongdoing

Have you made the protected disclosure to any other organisation? (required)

Yes

Information about you

Your name (required)

Email (required)

Phone number (required)

Enter numbers only, without spaces

I work (or used to work) for the organisation where the serious wrongdoing happened as: (required)

an employee

a contractor

a volunteer

a secondee

other

Your role in the organisation (required)

Do you still work for the organisation? (required)

Yes

I want my name, role and contact details kept confidential (required)

Yes

Your identity information may be disclosed with your consent or where allowed by the Protected Disclosures (Protection of Whistleblowers) Act 2022 (section 17).

Declaration

By submitting this form, I declare that this disclosure is made in good faith and to the best of my knowledge, the information provided is true and correct

Privacy

Information you provide about yourself will be kept as outlined in WorkSafe’s privacy statement and policy.

Protected disclosure form

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