EmailMe Form - MNCCC KCM OOSHC Whistleblower and PD Form

MNCCC KCM OOSHC Whistleblower and PD Form

Disclosures made via this form will be managed in accordance with the MNCCC Kids Crazy Maze OOSHC Whistleblower and Protected Disclosures Policy. The Policy is available on the MNCCC Kids Crazy Maze OOSHC (Wilderness Activity Centre) website.

Please note that any disclosures made in this form are not provided to MNCCC Kids Crazy Maze OOSHC, but to an external independent service that acts for the MNCCC Kids Crazy Maze OOSHC. However, any information provided through this form may be provided in whole or in part to MNCCC Kids Crazy Maze OOSHC, in accordance with the Policy.

This Disclosure Service is operated externally to MNCCC Kids Crazy Maze OOSHC. The ability of the Disclosure Service to respond to the concerns raised can be limited if we are unable to follow up with the whistleblower/discloser directly, and as such, we would encourage you to provide contact details. If you hold concerns regarding anonymity, you may wish to set up and provide details of an anonymous email account so that such follow up can occur. This information will not be provided to MNCCC Kids Crazy Maze OOSHC without your consent.

1. Are you aware of/have you read the MNCCC Kids Crazy Maze OOSHC Whistleblower and Protected Disclosures Policy? *
Yes - I have read and am aware of the Policy
Yes - I am aware of but have not read the Policy
No - I am not aware of and have not read the Policy
2. Would you like to raise your concern anonymously? *
Yes (Please move to question 3).
No (Please provide your details below and move to question 4).
Name
First Last
Phone
### - ### - ####
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
3. If providing an anonymous concern, do you consent to providing your details to the external whistleblower/disclosure service?
No - I do not wish to provide my name or details to anyone (Please move to question 4).
Yes - I will provide my name and details to the external whistleblower/disclosure service, but do not want them provided to any third party including MNCCC Kids Crazy Maze OOSHC (Please provide your details below).
Please note that we may be legally obliged to provide any information regarding certain conduct such as criminal conduct to external authorities including the Police or relevant Child Protection agencies.
Name
First Last
Phone
### - ### - ####
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
4. Are you completing this form on behalf of another person? *
Yes (Please provide your details below)
No (Please move to question 5)
Name
First Last
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Nature of the Concern

5. Does the MNCCC Kids Crazy Maze OOSHC Whistleblower and Protected Disclosures Policy apply to you? *
Yes- I am a current employee of MNCCC Kids Crazy Maze OOSHC
Yes - I am a former employee of MNCCC Kids Crazy Maze OOSHC
Yes- I am a current officer of MNCCC Kids Crazy Maze OOSHC (e.g. board member)
Yes - I am a former officer of MNCCC Kids Crazy Maze OOSHC (e.g. board members)
Yes - I am a current contractor, consultant or service provider who has provided goods or services to MNCCC Kids Crazy Maze OOSHC
Yes - I am a former contractor, consultant or service provider who has provided goods or services to MNCCC Kids Crazy Maze OOSHC
Yes - I am a current volunteer who has provided goods or services to MNCCC Kids Crazy Maze OOSHC
Yes - I am a former volunteer who has provided goods or services to MNCCC Kids Crazy Maze OOSHC
Yes - I am a spouse, relative or dependant of the categories listed above
Yes - I fall within one of the above categories but choosing the appropriate category may reveal my identity
No - I do not fall within one of the above categories (Please note you may not be considered an eligible discloser under the Policy, and as such, may not be afforded whistleblower/discloser protections).
If you are do not fall into one of the above categories, please specify your relationship to MNCCC Kids Crazy Maze OOSHC:
Please note you may not be considered an eligible discloser under the Policy, and as such, may not be afforded whistleblower/discloser protections.
Are you making this disclosure as a whistleblower complaint or as a protected disclosure?
Whistleblower complaint
Protected disclosure
Unsure
6. If known, please provide the name/s of the person/s to whom this concern is regarding (or details which may assist in identifying the relevant person) *
7. Please outline the concern with as much detail, including the following if possible:
- The alleged improper conduct as specified in the Policy?
- Who was involved?
- When did it occur?
- What are the grounds for believing that the conduct occurred? *
8. Please provide any evidence or supporting documentation.
9. Will you send (other) supporting documents by mail or email?
Yes - by email
Yes - by mail
No
If you have additional information or would like to send supporting documents by email, please send to mnccckidscrazymazewhistleblower@integroe.com.au. Physical documents can be sent via mail to lntegroe Partners, Suite 5 3-7 Park Ave, Drummoyne NSW 2047.
10. Please indicate if you would like to speak with someone from the external service to provide information: *
Yes
No
11. If yes, please ensure that you provide your contact details below.
Thank you for taking the time to submit these concerns.

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