Woman Within® International - Whistleblower Form
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Before completing this form - please consider whether the matter of concern may be more appropriately raised under the Woman Within Grievance Policy

All members of Woman Within International are encouraged to raise genuine concerns in good faith, about possible illegal matters of financial reporting and other malpractices at the earliest opportunity, and in an appropriate way.

This form not only covers possible improprieties in matters of financial reporting, but also:
*fraud;
*corruption, bribery or blackmail;
*criminal offences;
*failure to comply with a legal or regulatory obligation;
*miscarriage of justice;
*endangering the health and safety of an individual; and
*concealment of any of the above.

The Whistleblower reporting such improprieties should be informed that
*As far as lies in the organisation’s power, the Whistleblower will not be disadvantaged for the act of making such a report; and
*If the Whistleblower wishes to make their complaint anonymously, their wish shall be honoured except insofar as it may be overridden by due process of law; however,
*Reporting such an impropriety does not necessarily absolve the Whistleblower from the consequences of any involvement on their own part in the misconduct complained of.


CONTACT INFORMATION
You have the right to remain anonymous, except insofar as it may be overridden by due process of law.

Please note that the maintenance of such anonymity may make it less likely that the alleged breach can be substantiated in any subsequent investigation.

Where anonymity has been requested you are required to maintain confidentiality regarding the issue on your own account and to refrain from discussing the matter with any unauthorised persons.
I would like to remain anonymous *
If you have chosen to remain anonymous, you are required to maintain confidentiality regarding the issue on your own account and to refrain from discussing the matter with any unauthorised persons. *
Your full name
Your region
Preferred Telephone number
Email
THE REPORT
Specify the  nature of the alleged impropriety? *
Who are/ is the The person or persons responsible for the impropriety? *
The facts on which you believe that an impropriety has occurred, and has been committed by the person named above, are founded *
EVIDENCE
Evidence to support such concerns should be brought forward at this time if it exists and emailed to the email you receive,  on completion of this form and it had been submitted.

The absence of such evidence will be taken into account in subsequent consideration of whether to open an investigation into the matter. However, absence of such evidence is not an absolute bar to the activation of the organisation’s investigative procedures. The existence of such a concern is sufficient to trigger reporting responsibilities.

The nature and whereabouts of any further evidence that would substantiate your allegations, if known *
Do you have any witnesses to substantiate your allegations? Please provide their names and contact details (email / telephone number) *
INVESTIGATION
I understand that if it is to be found that the behaviour complained of to be unquestionably trivial or fanciful, that the allegation will be dismissed, and that I will be informed of this decision.   *
I understand that if it is to be found that the behaviour complained of to be neither trivial nor fanciful, an investigation process as described in the policy will be put into place. *
I understand that an investigating committee will be formed and that outside counsel may be sought, where relevant.
Clear selection
I understand that a reasonable timeframe will be needed to carry out the investigation, and that I will receive feedback if I have not chosen to remain anonymous. *
I understand that in finalising the Whistleblower Process, the Leadership Circle / Board  shall receive a report once the investigation is complete. This report will be shared verbally with the  Whistleblower (if not anonymous). *
Protection
Where the investigation has found that the Whistleblower acted in good faith on reasonable grounds, the Leadership Circle / Board shall designate the programming director  to be responsible for ensuring that the Whistleblower suffers no Leadership related disadvantage on account of their actions in this matter and to provide additional support for the person where necessary


SIGNATURE *
By printing my full name below, I agree that all information provided in this form is true and correct. Writing your name constitutes an electronic signature which is legally binding and has the same legal status as handwritten signatures throughout the United States, under the ESIGN Act and the Uniform Electronic Transactions Act (UETA).  If you are reporting anonymously then please type Anonymous.
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