Whistleblower FormBy rocjpc / November 7, 2026 Date Submitted: Name: (optional) Preferred Contact Information: (optional) Relationship To JPC:EmployeeVolunteerDirector/OfficerContractorClient/ParticipantPublicOther:Person Whose Conduct is Being Reported: Date(s) / Time Period of Concern: Location / Program / Department Involved: Describe what happened. Include specific facts, statements, actions, dates, and circumstances: How did you hear about the concern? What did you personally observe? Identify witnesses or other people who may have relevant information: Identify documents, emails, records, or other evidence that may exist and where they may be located: Has this concern been reported previously? If yes, to whom, when, and what happened? Do you believe there is an immediate risk of harm, retaliation, loss of records, financial loss, or other urgent concern? Explain: What outcome or follow-up do you believe should be considered? (Optional)
