Whistleblower Response Form

Personnel are encouraged to report activities that they, in good faith, believe to be fraudulent or dishonest conduct or violation of Dzokden corporate policies (i.e., act as a “whistleblower”), some examples of which include, but are not limited to, the following:

  • forgery or alteration of documents or materials;

  • unauthorized alteration or manipulation of computer or physical files;

  • fraudulent financial reporting;

  • pursuit of a benefit or advantage in violation of Dzokden's Conflict of Interest Policy; 

  • misappropriation or misuse of Dzokden's resources, such as funds, educational materials; supplies, or other assets;

  • authorizing or receiving compensation for goods not received or services not performed; and

  • authorizing or receiving compensation for hours not worked

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 Is this the first time you are filing a report for the improper conduct?
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Please state the date(s) or approximate date(s) of your previous report(s).
Name of Person Filing Report
You are not required to provide your name and may retain anonymity. If you choose to provide your name, it will remain confidential whenever possible. Providing your name may facilitate the investigation of the misconduct. Anyone filing an anonymous report will not be updated as to the progress of the investigation, but do understand that investigations are taken seriously and will be addressed. Making a complaint does not automatically shield you from consequences of your own involvement in unlawful or improper conduct. However, full and frank admissions may be considered in deciding disciplinary actions.

Name of Person(s) Subject to this Complaint
Name and position(s) of the person(s) you think committed the offense.
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