Whistleblower Report Form

A whistleblower can be any employee, student, vendor, guest, alumnus/alumna, or supporter of the university who has direct knowledge, or a reasonable concern, that the university or any of its agents is acting contrary to any applicable federal, state or local laws or contrary to an established ��ý policy. Whistleblowers are encouraged to report the activity and may do so without fear of reprisal or retaliation. The policy and process are under the supervision of the Vice President for Finance & Risk Management and the Vice President for Student Success.

The whistleblower must initiate the process as defined on the University’s external website or the intranet website. The relevant links are included in the “Report It” section. The adjudicator of the report will inform the reporting individual upon receipt of the report and at the conclusion of the investigation. The investigation shall normally be completed within 60 days.

First Name:

Last Name:

Email Address:

Phone Number:

Address (optional):

I am filing this report as a: Student Faculty / Instructor / Coach Staff Alumnus / Alumna Other concerned individual

This concern is about: (please check all that apply below): Senior Administrative Staff (Cabinet Members) Supervisor Faculty Staff Unknown

Date of event causing concern: (MM/DD/YYYY, no specific date, or unknown)

Please describe the details of the event or circumstances of your concern:

Please indicate the name of the person or persons about which you are filing this report and what, if any, interaction you normally have with this person. (i.e. my supervisor, my co-worker, my coach, or I have no relationship with this person.):

Other Witnesses:

Include Name and Phone Number of each.

Signature of individual submitting report:

Type your name to sign.

Date:

Today's date was autofilled.

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Whistleblower Report Form

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