Disclosure Form for Federal Public Sector Employees and Members of the RCMP
This HTML document is not a form. Its purpose is to display the information as found on the form for viewing purposes only. If you wish to submit a form, you must use the Microsoft Word version.
Submit completed forms by mail, fax or in person to:
Office of the Public Sector Integrity Commissioner of Canada
60 Queen Street, 4th Floor
Ottawa, Ontario K1P 5Y7
613-941-6400 or 1-866-941-6400 (toll-free)
Fax: 613-946-2151 (not a secure means of transmission)
This form is only intended for public servants making a disclosure of wrongdoing that is alleged to have occurred within a federal public sector organization.
Please respond to all question to the best of your ability. Contact the Office at 1-866-941-6400 if you require assistance. We strongly recommend you read through all questions prior to filling out this form.
General Contact Information
Name:
Job title or Rank (RCMP):
Current employer:
Current Branch or unit:
Address where you would like to be contacted (does not have to be your work address):
Telephone number(s):
Fax (optional):
Official language of choice for correspondence: English French
Email*:
*NOTE: The Office of the Public Sector Integrity Commissioner does not accept reprisal complaints or disclosures of wrongdoing via e-mail due to security and privacy concerns. The majority of communication between the Office and you will be undertaken via regular mail correspondence or by telephone. However, for increased convenience, correspondence regarding basic status update of files or setting up interviews may be sent by email.
Representation
Although not a requirement, some individuals may choose to be represented by someone to assist them in dealing with their disclosure.
1. If you are represented (e.g., legal counsel, union representative or other), please provide their contact information.
Name:
Organization:
Email:
Title:
Telephone:
2. Do you want the Office of the Public Sector Integrity Commissioner to contact you directly or through your representative? (choose one of the following)
Through my representative
Contact me directly
3. Correspondence (choose one of the following)
Send correspondence to my representative as well as to me
Send correspondence to me only
Information about your Disclosure of Wrongdoing
Under the Public Servants Disclosure Protection Act wrongdoing in or relating to the public sector can include:
- a contravention of any Act of Parliament or of the legislature of a province, or of any regulations made under any such Act;
- a misuse of public funds or a public asset;
- a gross mismanagement in the public sector;
- an act or omission that creates a substantial and specific danger to the life, health or safety of persons, or to the environment, other than a danger that is inherent in the performance of the duties or functions of a public servant;
- a serious breach of a code of conduct; and
- knowingly directing or counselling a person to commit a wrongdoing
4. Using your own words, while keeping in mind the definition of wrongdoing above, please describe the situation. Include: who (name and title) you believe committed wrongdoing; what your specific allegations are; when and where (which federal department/organization) the alleged wrongdoing occurred. Identify any applicable Acts, Regulations, Policies or Directives relating to the wrongdoing. For example if the wrongdoing you are reporting refers to the contravention of an Act, indicate which Act.
Please include the contact information for the individuals you allege committed the wrongdoing:
Name:
Title or Rank (RCMP):
Federal Department/Organization:
Work Unit:
Work Telephone:
Work Address:
Name:
Title or Rank (RCMP):
Federal Department/Organization:
Work Unit:
Work Telephone:
Work Address:
5. Do you have documentation or evidence to support you allegations?
Yes
No
You may attach supporting documentation or additional information if necessary. Do not include information that is protected by solicitor / client privilege or Cabinet confidences. To ensure a timely review of your case, only provide documentation that supports your allegations, specifying which portions you deem relevant to the alleged wrongdoing.
Other Proceedings
Restrictions
According to the Public Servants Disclosure Protection Act, there are certain circumstances where the Commissioner must refuse to deal with a disclosure or start an investigation, such as when another person or organization is already dealing with the issue under another Act of Parliament. Make sure to include in your answer to the questions below whether, to your knowledge, the issue is being addressed elsewhere (see Subsection 23(1) of the Act).
In addition, the Commissioner must refuse to deal with certain disclosures if he believes that the subject-matter of the disclosure relates solely to a decision made under an Act of Parliament (see Subsection 24(2) of the Act), including a decision of the Commissioner of the RCMP under Part IV of the Royal Canadian Mounted Police Act. Adjudicative decisions include decisions made by judges or tribunals in the course of a hearing.
Commissioner’s discretion
In some instances, the Commissioner may refuse to deal with a disclosure or start an investigation – and he may cease an investigation (see Paragraph 24(1)(a) to (f) of the Act) – if he believes, for example, that the subject-matter of the disclosure or the investigation has been adequately dealt with, or could more appropriately be dealt with, according to a procedure provided for under another Act of Parliament. For example, a privacy breach complaint may be better dealt with by contacting the Office of the Privacy Commissioner or a human rights violation could be reported to the Canadian Human Rights Commission.
Some issues that appear wrong, may not be considered wrongdoing under the Public Servants Disclosure Protection Act and may be more appropriately dealt with via other recourse mechanisms. For more information, visit www.psic-ispc.gc.ca/eng/wrongdoing/other-recourse-mechanisms
6. Have you already raised your concerns through another mechanism?
No
Yes
How were the concerns raised? Check all that apply.
Departmental Senior Officer for internal disclosure
Supervisor/Manager
Grievance
Harassment complaint
Other formal complaint (Privacy Act, Access to Information Act, Human Rights complaint, etc.)
Other
For members of the RCMP only:
If you are a member of the RCMP, is the subject-matter of this disclosure of wrongdoing currently being dealt with by the RCMP pursuant to Part IV of the RCMP Act?
No
Yes
7. If you selected yes or one or more of the options above:
a. Please identify the person/entity to whom to made the report, provide relevant dates and describe any actions or decision taken as a result of your report.
Explain:
b. What action, if any has been taken?
Explain:
c. If the matter has not been resolved, ehat is the current status?
Explain:
Declaration
I declare that all of the information provided is true and accurate to the best of my knowledge.
I understand that it is my responsibility to provide the Commissioner with all of the information required by this form, and to attach to this form any relevant documentation.
Signature
Date
Note:
By submitting the Disclosure Form, you are authorizing the Office of the Public Sector Integrity Commissioner to collect your personal information.
This information is being collected solely for purposes related to the application of the Public Servants Disclosure Protection Act. Accordingly, a representative from the Commissioner’s Office may contact you for further information.
The disclosure process is confidential. Your identity and other information provided to the Office of the Public Sector Integrity Commissioner will be protected to the extent possible under applicable laws. Such information obtained or created by the Office of the Public Sector Integrity Commissioner in the course of an investigation into a disclosure of wrongdoing cannot be released under the Access to Information Act or the Privacy Act.