Whistle Blower Form - Guyana Gold Board

Date of Report

Date

Time

Do you wish to report anonymously?

Yes: I wish to report anonymously.
No: I wish to disclose my Identity and request confidentiality from the recipient of the report.

Incident Details

Date of the incident:

Date

Time

Nature of the incident:

Person(s) or Entity(ies) Involved

Incident Location

Is this incident recurring?

Yes
No
Unsure

By reporting a wrongdoing, you declare the following:

I am disclosing the information in good faith; I believe the information to be substantially true; I am not acting maliciously or making false allegations; and I am not seeking any personal or financial gain.

Note

All reports submitted here are fully confidential. Your identity will remain protected. You may optionally provide your contact information if you would like us to follow up with you.

Reporter's of staff:

Reporter's Email

Reporter's Number

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Warning:

Making any deliberately false or malicious allegations is a serious disciplinary offence, which may result in disciplinary or legal action against you.