Reprisal (Public Servants)

Microsoft Word Version

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Reprisal Complaint Form for All Current and Former Public Sector Employees (Other Than Members of the RCMP)

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:
Title (optional)
Name of employer
Current organization if other that employer
Branch or unit
Address where you would like to be contacted
Telephone number(s) at which you would like to be contacted
Fax (optional)
E-mail (optional)

(1) Are you represented by someone (e.g., legal counsel, union representative or other)?

No
Yes
Please provide name, title and contact information for your representative

(2) Do you want the Office of the Public Sector Integrity Commissioner to contact you directly or through your representative? (choose one of the following)

Through my representative
Contact me directly

Correspondence (choose one of the following)

Send correspondence to my representative as well as to me
Do not send correspondence to my representative but only to me

(B) Employment Status

Are or were you:
Currently employed in the public sector
or
Formerly employed in the public sector
Name of Employer where reprisal(s) occurred:

(C) Information about your Reprisal Complaint

Definition of Reprisal

Under the Public Servants Disclosure Protection Act, a "reprisal" means any of the following measures taken against a public servant because the public servant has made a protected disclosure or has, in good faith, cooperated in an investigation into a disclosure or an investigation commenced under section 33:

(a) a disciplinary measure;
(b) the demotion of the public servant;
(c) the termination of employment of the public servant, including, in the case of a
member of the Royal Canadian Mounted Police, a discharge or dismissal;
(d) any measure that adversely affects the employment or working conditions of the public servant; and
(e) a threat to take any of the measures referred to in any of paragraphs (a)
to (d).

(1) Please describe any measures taken against you that constitute reprisal (see definition of reprisal above):

(Attach supporting documentation or use appendix if necessary.)

(2) Please identify the date(s) on which reprisal(s) was or were taken against you:

(3)  Please identify the date(s) on which you became aware of reprisal(s), if different from the date of the actual reprisal(s):

(4) Time Limit

Time limit for filing a reprisal complaint

Subsection 19.1(2) of the Public Servants Disclosure Protection Act provides that a reprisal complaint must be filed not later than 60 day after the day on which the complainant knew, or in the Commissioner’s opinion ought to have known, that the reprisal was taken.

The Commissioner may extend the 60-day period to file a complaint if he or she believes that an extension is appropriate considering the circumstances of the complaint.

If you are filing your complaint outside the 60-day limitation period, please explain the reasons for the delay:

(Attach supporting documentation or use appendix if necessary.)

(5) Please identify the person(s) alleged to be responsible for the reprisal(s):

1. Name
Employer
Work address
Telephone number(s)
Fax (optional)
E-mail (optional)

2. Name
Employer
Work address
Telephone number(s)
Fax (optional)
E-mail (optional)

3. Name
Employer
Work address
Telephone number(s)
Fax (optional)
E-mail (optional)

(Use appendix if necessary.)

(6) To constitute a “reprisal”, the measure(s) you identified above must have been taken against you because you made a protected disclosure of wrongdoing in good faith or cooperated in an investigation into a disclosure of wrongdoing.

You are protected against reprisal if you made a protected disclosure concerning a wrongdoing to:

(1) your supervisor; or
(2) the designated Senior Officer appointed in your organization under the
Public Servants Disclosure Protection Act; or
(3) the Public Sector Integrity Commissioner.

You are also protected if you disclosed wrongdoing:

(1) in the course of a Parliamentary proceeding;
(2) in the course of a procedure established under any other Act of Parliament; or
(3) when lawfully required to do so.

Did you make a protected disclosure of wrongdoing or have you cooperated in an investigation?

Yes - Please provide details, including relevant dates and names of the people to whom or the office to which you made a protected disclosure:

(Attach supporting documentation or use appendix if necessary.)

No

(D) Other Proceedings

Subsection 19.3(2) of the Public Servants Disclosure Protection Act provides that the Commissioner cannot deal with a reprisal complaint if a person or body acting under another Act of Parliament or a collective agreement is currently dealing with the subject-matter of the complaint.

(1) Is the subject-matter of this reprisal complaint currently being dealt with under another Act of Parliament or under a collective agreement (for example, have you made a complaint to another agency or body or have you filed a grievance)?*

Yes - Please provide details:

(Attach any relevant documents.)

No

(2) Has the subject-matter of this reprisal complaint previously been dealt with under another Act of Parliament or under a collective agreement (for example, through a complaint to another agency or body or a grievance)?*

Yes - Please provide details:

(Attach any relevant documents.)

No

* Explanatory Notes

Commissioner’s Discretion

Subsection 19.3(1) of the Public Servants Disclosure Protection Act provides that the Commissioner may refuse to deal with a complaint if he or she is of the opinion that the subject-matter of the complaint has been adequately dealt with, or could more appropriately be dealt with, according to a procedure provided for under an Act of Parliament, other than this Act, or a collective agreement.

(D) Declaration

I make this complaint 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 Complaint 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 information is held in Personal Information Bank PSIC PPU 006 and you have a right to access this information in accordance with the Privacy Act.