Safe Disclosure Reporting Form - Simon Fraser University

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This form covers complaints made under the <u>Public Interest Disclosure Act</u> and <u><a href="https://www.sfu.ca/policies/gazette/general/gp41.html">GP41 - Safe Disclosure of Wrongdoing</a></u>. Learn more about the policies and how they differ by visiting the <a href="/main/sfu-community/community-supports/safe-disclosure.html">Safe Disclosure of Wrongdoing or Reprisal webpage</a>.</p> <p>To begin your complaint, please submit the form below.</p> <p><i><b>Important: Please note that progress on this form cannot be saved. 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Which policy do you believe best matches your complaint?</b> </legend> <label><input type="radio" name="there-are-two-policies-which-complaints-can-be-filed-under-which-policy-do-you-believe-best-matches-your-complaint" value="GP41 - Safe Disclosure of Wrongdoing - For isolated incidents of misconduct at SFU" class="" data-required><b>GP41 - Safe Disclosure of Wrongdoing - For isolated incidents of misconduct at SFU</b> </label> <label><input type="radio" name="there-are-two-policies-which-complaints-can-be-filed-under-which-policy-do-you-believe-best-matches-your-complaint" value="Public Interest Disclosure Act (PIDA) - For ongoing / systemic wrongdoing or reprisal committed at SFU" class="" data-required><b>Public Interest Disclosure Act (PIDA) - For ongoing / systemic wrongdoing or reprisal committed at SFU</b> </label> <label><input type="radio" name="there-are-two-policies-which-complaints-can-be-filed-under-which-policy-do-you-believe-best-matches-your-complaint" value="I'm not sure " class="" data-required><b>I'm not sure </b> </label> </fieldset> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="dropdown field section"><label> <b class="required-field">Please specify your affiliation with SFU at the time of the incident</b> <select name="please-specify-your-affiliation-with-sfu-at-the-time-of-the-incident" class="" data-required> <option value="SFU Employee (Faculty or Staff)">SFU Employee (Faculty or Staff)</option> <option value="Former SFU Employee">Former SFU Employee</option> <option value="SFU Student">SFU Student</option> <option value="Current Board of Governors' Member">Current Board of Governors' Member</option> <option value="Former Board of Governors' Member">Former Board of Governors' Member</option> <option value="Contractor">Contractor</option> <option value="Agent">Agent</option> <option value="Volunteer">Volunteer</option> </select> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text-area field section"><label> <b class="required-field">Describe the nature of your concern, including sufficient information for an independent investigator to thoroughly understand the concern:</b> <textarea name="describe-the-nature-of-your-concern-including-sufficient-information-for-an-independent-investigator-to-thoroughly-understand-the-concern" class="" data-required></textarea> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text-area field section"><label> <b class="required-field">Provide any details you can about the location, date and time of the incident:</b> <textarea name="provide-any-details-you-can-about-the-location-date-and-time-of-the-incident" class="" data-required></textarea> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text-area field section"><label> <b class="required-field">Describe how you became aware of the incident:</b> <textarea name="describe-how-you-became-aware-of-the-incident" class="" data-required></textarea> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text-area field section"><label> <b class="required-field">State the full name, title and role of each individual you suspect of wrongdoing:</b> <textarea name="state-the-full-name-title-and-role-of-each-individual-you-suspect-of-wrongdoing" class="" data-required></textarea> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text-area field section"><label> <b class="required-field">To the best of your knowledge, how many times has this incident taken place?</b> <textarea name="to-the-best-of-your-knowledge-how-many-times-has-this-incident-taken-place" class="" data-required></textarea> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text-area field section"><label> <b class="required-field">To the best of your knowledge, how long has the incident been taking place for?</b> <textarea name="to-the-best-of-your-knowledge-how-long-has-the-incident-been-taking-place-for" class="" data-required></textarea> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text-area field section"><label> <b class="required-field">Have you reported the wrongdoing to your supervisor, another manager, or through another process (e.g. Human Rights policy, Sexualized Violence policy, labour relations grievance, the RCMP or local police, etc?) If yes, please provide the status, and/or any response you have received:</b> <textarea name="have-you-reported-the-wrongdoing-to-your-supervisor-another-manager-or-through-another-process-e-g-human-rights-policy-sexualized-violence-policy-labour-relations-grievance-the-rcmp-or-local-police-etc-if-yes-please-provide-the-status-and-or-any-response-you-have-received" class="" data-required></textarea> </label> <span class="required-error-message" style="display:none;"><span>This is required.</span></span> <span class="field-description"></span> </div> <div class="text parbase section"> <div class=""> </div></div> <div class="text parbase section"> <div class="ruled above"> <h3>Your Information and Anonymity</h3> <p>Reports of wrongdoing or reprisal can be made anonymously and you are not required to share your personal information to submit a complaint. However, an investigator may need to contact you with additional questions or to clarify information to support their investigation. If you do not include your contact information, it may limit the ability of the investigator to complete the investigation.</p> </div></div> <div class="text-field field section"><label> <b>Your First and Last Name</b> <input type="text" name="your-first-and-last-name" class="" value=""> </label> <span class="field-description"></span> </div> <div class="text-field field section"><label> <b>Your E-Mail Address</b> <input type="text" name="your-e-mail-address" class="" value=""> </label> <span class="field-description"></span> </div> <div class="text-field field section"><label> <b>Your Phone Number</b> <input type="text" name="your-phone-number" class="" value=""> </label> <span class="field-description"></span> </div> <div class="checkbox-group field section"><fieldset> <legend> <b class="required-field">The information provided above is true, shared in good faith and I have a reasonable belief that wrongdoing or reprisal has occurred or will occur.</b> </legend> <label><input type="checkbox" name="the-information-provided-above-is-true-shared-in-good-faith-and-i-have-a-reasonable-belief-that-wrongdoing-or-reprisal-has-occurred-or-will-occur" value="I agree" class="" data-required><b>I agree</b> </label> </fieldset> <span class="required-error-message" style="display:none;"><span>You must accept these terms to submit your complaint</span></span> <span class="field-description"></span> </div> <div class="spam-protection field section"><script src='https://www.recaptcha.net/recaptcha/api.js' async defer></script> <div class="g-recaptcha" data-callback="recaptchaCallback" data-expired-callback="recaptchaExpiredCallback" data-sitekey=6LcsiKMZAAAAAOddHfPVP6Dd-8_bNAWGYWFWn-Ex></div> <noscript> <div style="width: 302px; height: 352px;"> <div style="width: 302px; height: 352px; position: relative;"> <div style="width: 302px; height: 352px; position: absolute;"> <iframe src="https://www.recaptcha.net/recaptcha/api/fallback?k=6LcsiKMZAAAAAOddHfPVP6Dd-8_bNAWGYWFWn-Ex" frameborder="0" scrolling="no" style="width: 302px; height:352px; border-style: none;"> </iframe> </div> <div style="width: 250px; height: 80px; position: absolute; border-style: none; bottom: 21px; left: 25px; margin: 0px; padding: 0px; right: 25px;"> <textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 80px; border: 1px solid #c1c1c1; margin: 0px; padding: 0px; resize: none;" value=""> </textarea> </div> </div> </div> </noscript> <span class="constraint-error-message" style="display:none;"><span>This must be checked.</span></span> <span class="field-description"></span> </div> <div class="end section"> <div class="form_row"> <div class="form_leftcol"></div> <div class="form_rightcol"> <button type="submit" name="Submit" value="Submit"> Submit </button></div> </div><div class="form_row_description"></div> </div></form></div> <div class="text parbase section"> <div class=""> <h4>Collection Notice</h4> <p>SFU collects your personal information and any additional information provided in the above form in accordance with Freedom of Information and Protection of Privacy Act (RSBC 1996, c. 165)("FIPPA") and the Public Interest Disclosure Act (SBC 2018, 22)(“PIDA”) and University Policy GP 41 - Protected Disclosure of Wrongdoing Policy (GP41). The information is related directly to and needed by the University for the purposes of addressing and investigating disclosures made under PIDA and in accordance with GP41. </p> <p>The information will be used to facilitate the reporting, investigation, and resolution of disclosures made under the PIDA Act, GP41, and any related university policies that may apply. This may include information related to alleged wrongdoing, mismanagement, or other concerns raised in the interest of public safety and organizational integrity. </p> <p>If you have any questions about the collection and use of this information please contact the Director of Internal Audit at iapida@sfu.ca. Simon Fraser University is located at 8888 University Drive, Burnaby, British Columbia, V5A 1S6.</p> </div></div> </div> <div class="below-main inherited-parsys"> </div> </div> </div> </div> </div> </section> </main> <footer> <section class="footer"> <div class="footer__content"> <div class="footer__content--sfu-global"> <div class="sfu-global--site-links"> <h5>Simon Fraser University</h5> <ul> <li> <a href="/main/admission.html">Admission</a> </li> <li> <a href="/main/programs.html">Programs</a> </li> <li> <a href="/main/learning.html">Learning</a> </li> <li> <a href="/main/sfu-community.html">Community</a> </li> <li> <a href="/main/about.html">About</a> </li> <li> <a href="/main/research.html">Research</a> </li> </ul> </div> <div class="sfu-global--contact-info"> <div class="contact-us inherited-parsys"> <div class="parsys"> <div class="text parbase section"> <div class=""> <h3>Contact us<br> </h3> <ul> <li><a href="https://www.sfu.ca//main/contact/burnaby.html">Burnaby 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