Disclosure (Public)

(Microsoft Word Version - 282 K)

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Disclosure Form for Members of the Public

Submit completed forms to:
Office of the Public Sector Integrity Commissioner of Canada
60 Queen Street
Ottawa, Ontario  K1P 5Y7
Telephone: 1-866-941-6400
Fax: 613-946-2151

(A) General Contact Information

Name:
Address where you would like to be contacted
Telephone number(s) at which you would like to be contacted
Fax (optional)
E-mail (optional)

(B) Information about your Disclosure of Wrongdoing (Subsection 33(1) of the
Public Servants Disclosure Protection Act)

(1) Please identify the wrongdoing that has been committed or that is ongoing:
Definition of wrongdoing (choose applicable section(s))

8. The Public Servants Disclosure Protection Act (the Act) applies in respect of the following wrongdoings in or relating to the public sector:

(a) a contravention of any Act of Parliament or of the legislature of a province, or of any regulations made under any such Act, other than a contravention of section 19 of this Act;
(b) a misuse of public funds or a public asset;
(c) a gross mismanagement in the public sector;
(d) an act or omission that creates a substantial and specific danger to the life, health or safety of persons, or to the environment, other than a danger that is inherent in the performance of the duties or functions of a public servant;
(e) a serious breach of a code of conduct established under section 5 or 6; and
(f) knowingly directing or counselling a person to commit a wrongdoing set out in any of paragraphs (a) to (e).

(2) Please identify the federal public sector organization where the alleged wrongdoing took place (department, agency or Crown corporation):

(3) Please provide a description of the wrongdoing. Identify any applicable acts or regulations, policies or directives relating to the wrongdoing:

(Attach supporting documentation or use appendix if necessary.)

(4) Please identify the location where the wrongdoing took place:

(5)  Please identify the date(s) on which the wrongdoing occurred or whether it is ongoing:

(6) If known, please identify the person(s) alleged to be responsible for the wrongdoing:

1. Name
Employer
Work address
Telephone number(s)

2. Name
Employer
Work address
Telephone number(s)

3. Name
Employer
Work address
Telephone number(s)

(C) Other Proceedings

Explanatory Notes:

Subsection 23(1) of the Act provides that the Commissioner may not deal with a disclosure or commence an investigation if a person or body acting under another Act of Parliament is dealing with the subject-matter of the disclosure or the investigation other than as a law enforcement authority.

Paragraph 24(1)(a) of the Act provides that the Commissioner may refuse to deal with a disclosure or to commence an investigation – and he or she may cease an investigation – if he or she is of the opinion that the subject-matter of the disclosure or the investigation has been adequately dealt with, or could more appropriately be dealt with, according to a procedure provided for under another Act of Parliament;

Subsection 24(2) of the Act provides that the Commissioner must refuse to deal with a disclosure or to commence an investigation if he or she is of the opinion that the subject-matter of the disclosure or the investigation relates solely to a decision that was made in the exercise of an adjudicative function under an Act of Parliament.

To the best of your knowledge, is the wrongdoing described above being dealt with (or has it been dealt with) by another federal organization?

No
Yes - Specify:

(Attach supporting documentation or use appendix if necessary.)

(D) Declaration

I make this disclosure in good faith and I declare that all of the information provided is true and accurate to the best of my knowledge.

I understand that it is my responsibility to provide the Commissioner with all of the information required by this form, and to attach to this form any relevant documentation.

Signature

Date

Note:

By submitting the Disclosure Form, you are authorizing the Office of the Public Sector Integrity Commissioner to collect your personal information.

This information is being collected solely for purposes related to the application of the Public Servants Disclosure Protection Act. Accordingly, an analyst / investigator from the Commissioner’s Office may contact you for further information.

The disclosure process is confidential. Your identity and other information provided to the Office of the Public Sector Integrity Commissioner when making in good faith a disclosure about a wrongdoing will be protected to the extent possible under applicable laws. Such information obtained or created by the Office of the Public Sector Integrity Commissioner in the course of an investigation into a disclosure cannot be released under the Access to Information Act or the Privacy Act or the Personal Information Protection and Electronic Documents Act. This information is held in Personal Information Bank PSIC PPU 005 and you have a right to access this information in accordance with the Privacy Act.