Serious wrongdoing reporting form

Before completing this form

Please ensure you have read and comply with the guidance provided on the Reporting wrongdoing webpage before completing this form.

 

Note that questions marked with an asterisk ( * ) are mandatory.

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.


Personal Details





Numbers only, eg 0212341234








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



Section 2: Summary of the wrongdoing



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



Person 1






Numbers only

Numbers only, eg 0212341234
Person 2






Numbers only

Numbers only, eg 0212341234
Person 3






Numbers only

Numbers only, eg 0212341234

Section 3: Information supporting the report



Witness 1





Numbers only

Numbers only, eg 0212341234


Witness 2





Numbers only

Numbers only, eg 0212341234


Witness 3





Numbers only

Numbers only, eg 0212341234


Section 4: Additional information



Note the size limits advised below, and that 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


Section 5: Preview and submit

Please review the information that you have provided and then complete the following statements. 




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.