| 1. Personal Details (if you wish to remain anonymous go to section 2) |
| First name | |
| Surname | |
| Address | |
| City | |
| State / Province | |
| Postcode | |
| Country | |
| Telephone 1 | |
| Telephone 2 |
Include country and area codes. |
| Email |
Ensure you've entered your email correctly.
|
| 2. Would you like to be contacted by us? |
| | Yes No
If YES, please specify the most suitable means and time:
|
| | Would you like us to provide you with feedback?
YesNo
Please note that the confidential nature of reports may restrict disclosure of details of the investigation.
You may wish for your name to be kept confidential. If that is the case, your name will not be disclosed without your consent. Any information received will be handled to ensure that your identity is not revealed to anyone outside the investigation team. |
| | Do you wish for your name to be kept confidential?
Yes No |
| 3 . The Report |
| Project name | |
| Country |
Country this submission pertains to. |
| Time and date |
Time Day/Month/Year of incident |
| | * What is the allegation about?
|
| | * Description of the alleged facts
|
| | * What are you basing your allegations on?
|
| | * Will you be providing us with documents supporting this allegation?
YesNo |
| |
* Date of submission
|
