Whistleblower Report Form

Elshaddia
Confidential Submission

Date of Report: ______________________

Name of Reporter (Optional): _______________________________________
(You may submit anonymously, but providing your name helps us conduct a thorough investigation.)

Phone Number or Email Address (Optional): _______________________________________

Relationship to Organization:
☐ Employee
☐ Volunteer
☐ Board Member
☐ Contractor
☐ Camp Participant
☐ Other: _______________________________________

1. Describe the Issue or Concern:

(Please provide as much detail as possible, including what happened, where, when, and who was involved.)

2. How did you become aware of this issue?

☐ Witnessed personally
☐ Heard from someone else
☐ Discovered through documents or records
☐ Other: _______________________________________

3. Has this issue occurred before?

☐ Yes
☐ No
☐ Unsure

If yes, please explain:

4. Have you previously reported this issue to anyone?

☐ Yes
☐ No

If yes, please provide details (who you reported to, date, outcome, etc.):

5. Do you have any supporting documents or evidence?

☐ Yes (please attach copies)
☐ No

6. Any additional information you wish to provide:

Signature: _______________________________________ (Optional)

Date: ______________________

Submission Instructions:

• Deliver to the Executive Director or Board Chairperson in a sealed envelope marked "Confidential."

• Or email to: [Insert confidential email address]