Whistleblower Form Step 1 of 4 25% The Whistleblower submission form is intended to encourage employees and others to make good faith reports of suspected fraud, wrong-doing, corruption, or other improper or unethical activity that may adversely impact the college, employees, students, customers, board members, or the public at large. The form can also be used for health and safety concerns or to report a blatant disregard to the high standards of customer service.Do you work for the company/entity which you are submitting a report about?YesNoAt which location are you employed?Community Care CollegeClary Sage CollegeOklahoma Technical CollegeClary Sage SalonWhat type of incident would you like to report?Abuse of BenefitsAccounting, Auditing, and Internal Financial ControlsBullyingCode of Ethics ViolationCompliance, Regulation or Accreditation ViolationConflict of InterestCustomer ServiceDiscriminationEmbezzlementEmployee RelationsEnvironmental IssuesFalsification of Contracts or RecordsFraudHarassmentHostile Work EnvironmentImproper Giving or Receiving or GiftsIT SecuritySabotage or VandalismSafety ConcernsSexual HarassmentStudent RelationsSubstance AbuseTheft of PropertyThreat of ViolenceTime AbuseUnusual or Suspicious ActivityWaste/AbuseWillful MisconductOtherDescription:Improper or deceiving actions, including falsification of records or physical conditions related to benefit plans including paid time off programs.Description:Questionable procedures relating to accounting, auditing, or financial controls. (Examples include misstatement of financial reports, violations of Generally Accepted Accounting Principals, billing issues, information security, and financial concerns).Description:Aggressive behavior that involves unwanted, negative actions repeated over time with an imbalance of power or strength. The influence may be social and/or physical.Description:Violation relating to the organization's code of ethics.Description:Violations of a rule, regulation, law, operating procedure, past practice or protocol.Description:Actions that influence the exercise of one’s duty of loyalty. (Examples include inappropriate vendor relations, bribery, and exploitation of confidential information).Description:Failure to practice exceptional service to customers, clients, students, graduates, vendors, employers, or the community at large.Description:The denial of privileges or rights to individuals based on their race, color, ancestry, ethnicity, gender (sex), age, religion, origin, level of education, political affiliation, physical appearance, disability, marital status, or sexual orientation.Description:Fraudulently appropriating assets by an individual whom such property has been entrusted.Description:Issues related to the way employees work with each other; their supervisors/managers; and the company.Description:Violation of any environmental law, regulations, policy or procedures with respect to the handling and disposal of hazardous materials or actions affecting the health and safety of others.Description:Altering, fabricating, destroying, misrepresenting, or forging contracts or documents for personal gain.Description:A willful or deliberate act committed with the intention of obtaining money or property by misrepresentation, deception, or other unethical means.Description:Unwanted verbal or physical behavior of an inappropriate nature.Description:Speech or conduct severe or pervasive enough to create a hostile or abusive work environment using tactics such as verbal, nonverbal, psychological, physical abuse and humiliation.Description:Giving, receiving or solicitation of valuables which could be interpreted as an effort to influence a business relationship or decision.Description:Violations of information security policies, code of computer conduct that govern conduct while using the network or confidential information resources.Description:Select if the provided list of incidents does not describe the activity you are reporting.Description:The deliberate and willful destruction of, or damage and impairment to, equipment or property. Interference with normal processes, in order to cripple, shut down, or reduce the output of an operation.Description:Conditions that compromise the health, safety, and well-being of employees, customers, vendors, or visitors.Description:Unwanted and offensive sexual advances or sexually offensive remarks or acts. (Examples may include unwanted conversation, obscene gestures, comments, jokes, touching, staring/leering or whistling.)Description:The illegal or inappropriate use of drugs or alcohol resulting in a failure to fulfill major obligations at work, repeated absences, or poor work performance.Description:Stealing property belonging to the company or another without their consent.Description:Words or actions that threaten to inflict bodily harm on someone or someone's property and are made to intimidate, terrorize, frighten, harass, taunt, bully, or coerce.Description:The act of falsifying one’s own or other’s work hours.Description:Irregular activities that raise concern warranting an investigation.Description:Waste or abuse of property, vehicles, equipment or resources.Description:Any action, taken by an employee consciously and willfully, that is deliberately malicious, is unlawful, or violates a company policy. Please provide all details regarding the alleged violation, including any information that could be valuable in the evaluation of this situation. Please take your time and provide as much detail as possible, but exercise care to not provide details that may reveal your identity unless you wish to do so.What would you like to report? Please name the individuals involved in this activity.Where did the incident occur?When did the incident occur?How did you become aware of the incident? Did the incident occur more than once?YesNoWere you targeted in any way?YesNoWas there management involvement?YesNoWas there anyone else involved?YesNoHas the incident been reported to anyone in supervision or management?YesNoHas the incident been reported to anyone outside the organization?YesNoWere there any witnesses?YesNo Would you be willing to anonymously assist further if asked?YesNo Contact, I'm done. Skip the following questions and submit the report below.If yes, what email address can be used to anonymously communicate with you? By giving your email address we will be able to contact you on behalf of your employer if they have additional questions. Also, providing your email address can facilitate an anonymous dialog via email with your employer. Your employer will never see your email address. This will allow you to provide additional information and communicate directly with the company/entity's designated recipient. You will also be able to ask your employer about the status of your report.Do you give permission to share your contact information with your employer (waive your anonymity)?Yes, I wish to share my identity with my employer.No, I wish to remain anonymous.If Yes, please supply your name and email address or phone number. This information will be included in this report that will be sent to your employer’s designated recipient. Please note that a Yes response is authorizing us to divulge your name and contact information and you are waiving your anonymity.Name First Last PhoneEmail Best Time to Contact You?Do you have files to upload to support your report?YesNoFile This iframe contains the logic required to handle Ajax powered Gravity Forms.
