Whistleblower Submission Form Date Submitted: Name (optional): Preferred Contact Information: Relationship to JPC Employee Volunteer Director / Officer Contractor Client / Participant Public Other Person(s) 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 Learn About the Concern? What did You personally Observe? Identify Witnesses or Other People Who May Have Relevant Information: Identify Doucments, 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, Loff of Records, Financial Loss, or Other Urgent Concern? Explain: What Outcome or Follow-up Do You Believe Should be Considered? (optional): Good Faith Certification (Optional if Anonymous) I certify that the information I have provided is true and accurate to the best of my knowledge and belief. Signature: Send
