GSWPA Whistleblower Form

Do not use this report if the event you are reporting presents an immediate threat to life or property. Reports submitted through this venue may not receive an immeidate response. If you require emergency assistance, please contact your local authorities.

Select the location where the incident occurred:

Choose the type of report you would like to make:

Are you an employee of Girl Scouts Western Pennsylvania?

Do you wish to remain ANONYMOUS for this report?

If you want Girl Scouts Western Pennsylvania to know your identity, please complete the following:

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Best time for communication with you:

Please identify the person (s) involved in the alleged incident or violation including First Name, Last Name, Title.

Do you suspect or know that an employee of Girl Scouts Western Pennsylvania is involved?

If yes, then who?

Is management aware of this problem?

If yes, then who?

First Name/Last Name

What is the general nature of this matter?

This should be a general description only. You will be asked for specifics later.

Where did this incident or violation occur?

We recognize that this incident may not have occurred in a particular location. However, if this incident was observed in some documentation or business transactions, please indicate this accordingly.

Please provide the specific or approximate time this incident occurred.

Example: Tuesday, May 3, 20XX, Two Weeks ago, Approximately a month ago.

How long do you think this problem has been going on?

How did you become aware of this incident or violation?

Please identify any persons who have attempted to conceal this problem and the steps they took to conceal it, if applicable.

Example: Ignored it, Changed documents, Said it was not a problem, Said they would look into it.

Please provide all details regarding the alleged incident or violation, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation.

Please take your time and provide as much details as possible, but exercise care to not provide details that may reveal your identity unless you wish to do so. It may be important to know if you are the only person aware of this situation.

Girl Scouts Western Pennsylvania Whistleblower Policy