Section 1: Personal information

Note that you are not required to provide us with your personal details and may remain anonymous. However, doing so may reduce our ability to progress the report as we will not be able to contact you to verify or obtain further information. We will also not be able to advise you of the outcome of our assessment.

Any personal information you do provide will not be disclosed without your consent to anyone not involved in the assessment process or as otherwise required of the department under law.

Q1.1 Do you wish to provide your personal details?

Yes (complete the following fields) No (skip to Q1.2)

Personal details

Title (Mr, Mrs, Dr etc.)

Name

Email (this will be the main way we communicate with you)

Email (confirm email)

Telephone

Numbers only, eg 0212341234

Street address

Town / suburb

Postcode (numbers only)

Q1.2 Are you a NSW Government agency employee, contractor, or volunteer?

Yes (complete Q1.2a)
No (skip to Q1.3)Prefer not to say (skip to Q1.3)

Q1.2a If Yes, is this for the Department of Planning and Environment?

YesNo

Q1.3 Are you making this report on behalf of someone else?

Yes (complete Q1.3a)No (skip to Q1.4)

Q1.3a If Yes, do you have their consent to make this report on their behalf?

Yes complete Q1.3bNo (skip to Q1.4)

Q1.3b If Yes, what is the name of the other person?

If Yes, what is the name of the other person?

Q1.4 Have you (or the person above) submitted this report to another person/agency?

Yes (complete Q1.4a and Q1.4b)No (skip to Section 2)

Q1.4a If Yes, to which person or agency?

Q1.4b What was the response/outcome (if known)?

Section 2: Summary of the wrongdoing

Q2.1 Tell us what happened

Q2.2 When did it occur?

(be as specific as possible, listing multiple dates for multiple incidents)

Q2.3 Where did it occur?

Q2.4 Why do you consider it to be wrongdoing?

Q2.5 What are the details of the person/s who committed the wrongdoing?
[Enter as much information as possible or write “unknown”. If you wish to advise the details of other persons, select the button below to add. If needed, others may be added in “Any other relevant details below”]

1 Person2 People3 People

Person 1

Name:

What is their position title?

Business area:

Street address:

Town / suburb:

Postcode:

Numbers only

Telephone:

Numbers only, eg 0212341234

Person 2

Name:

What is their position title?

Business area:

Street address:

Town / suburb:

Postcode:

Numbers only

Telephone:

Numbers only, eg 0212341234

Person 3

Name:

What is their position title?

Business area:

Street address:

Town / suburb:

Postcode:

Numbers only

Telephone:

Numbers only, eg 0212341234

Any other relevant details?

Section 3: Information supporting the report

Q3.1 Are you aware of any potential witnesses to the wrongdoing?

Yes (complete Q3.1a)No (skip to Section 4)

Q3.1a Witness details
If you wish to advise the details of other persons, select the button below to add.

1 Person2 People3 People

Witness 1

Name:

Organisation:

Street address:

Town / suburb:

Postcode:

Numbers only

Telephone:

Numbers only, eg 0212341234

Is this person aware that you are making this report?

YesNoUnknown

What information does this person have?

Witness 2

Name:

Organisation:

Street address:

Town / suburb:

Postcode:

Numbers only

Telephone:

Numbers only, eg 0212341234

Is this person aware that you are making this report?

YesNoUnknown

What information does this person have?

Witness 3

Name:

Organisation:

Street address:

Town / suburb:

Postcode:

Numbers only

Telephone:

Numbers only, eg 0212341234

Is this person aware that you are making this report?

YesNoUnknown

What information does this person have?

Section 4: Additional information

Q4.1 Note anything else you wish to advise the department about your report

Q4.2 Upload any documents that are relevant to your report

Note the advised size limits and the department cannot accept executable files (e.g. video or audio)

File upload limits

Maximum total file size: 20MB
Maximum file name length: 64 characters
Maximum number of files to upload at once: 10
Total file upload limit: 10

Note

If you wish to provide further documents, either now or at a later date, please email them to ethics@dpie.nsw.gov.au noting the date and reference ID of your report.

You may also send further documents by post (though this is not preferred) to: Locked Bag 5022, Parramatta NSW 2124 (Attention Ethics Branch). Please include the date and reference ID of your report

Q4.2a If you have uploaded any documents, please explain how each supports your report

Section 5: Preview and submit

Please review your information provided and complete the following statements.

I declare that I have understood the questions and the information I have provided is true and complete to the best of my knowledge

Agree

I understand that it is an offence to provide false and misleading information to a public authority under Part 5A of the Crimes Act 1900 (NSW).

Agree

Note: Once you click on the "Submit" button below, you will be given an opportunity to preview (and edit if necessary) your completed form before confirming its submission.

If you have chosen to remain anonymous you should print a copy the report for your records at this time, then confirm submission. You should also record the reference ID for your report (this will display on your screen following submission), just in case you wish to contact us about it in future.

If you provided an email address in the form, a copy of your finalised report (including the ID reference number) will be emailed to you following submission.

Reporting serious wrongdoing

Before completing this form

Section 1: Personal information

Section 2: Summary of the wrongdoing

Section 3: Information supporting the report

Section 4: Additional information

Section 5: Preview and submit