Test

Contact Information

Name*

What pronouns would you like us to use?

A pronoun is a word used to refer to you in the third person (for example, they, she, he). We invite you to provide your pronouns so that we deliver our services in a way that is inclusive and safe for all people.

Pronouns

Untitled

I do not have pronouns, please refer to me by my name.

Prefer not to disclose (If you choose not to disclose, we will use your full name in all correspondence).

How would you like to be contacted?*

How would you like to be contacted?

Please check all that apply.

phone

mail

Address

Email communications with the BC Ombudsperson are subject to our email policy.

Telephone number*

May we leave a voice message?*

Yes

If you have any specific accessibility considerations or needs in order to participate in this process, please let us know below and we will do our best to meet them.

Employment Information

1. Are you a current or former employee of a public sector organization covered by PIDA?*

Yes

2. If so, which one?*

3. When did you work there?*

I work there now

I worked there from (enter start and finish dates)

Start date

Finish date

Job title*

Description of the reprisal

4. Was the reprisal related to*

seeking advice about the Public Interest Disclosure Act

making a report of wrongdoing under the Public Interest Disclosure Act

cooperating with an investigation under the Public Interest Disclosure Act

Please provide details about the above activity.

a) Who did you communicate with

a) Who did you communicate with?

b) What did you speak about?

c) When did you communicate?

d) How did you communicate?

5. What measure(s) of reprisal were taken against you?

Please check one or more of the following. *

a disciplinary measure

a demotion

a termination of employment

another measure which adversely affects your employment or working conditions

a threat to take any of the measures listed above

6. Please provide us with the following details:

a. Describe how your employment or working conditions were negatively impacted. *

b. Where did the reprisal(s) occur? (Organization and location) *

b. Where did the reprisal(s) occur? (Organization and location) *

c. Who took the measure(s) of reprisal against you?

c. Who took the measure(s) of reprisal against you? Please provide their name(s) and title(s). *

d. When did the reprisal measure(s) take place?

d. When did the reprisal measure(s) take place? If more than one incident of reprisal has occurred, please indicate the date the incidents began and their frequency or duration. *

e. What information do you have which supports that you suffered adverse consequences at work BECAUSE you sought advice, made a report of wrongdoing, or cooperated with an investigation?

e. What information do you have that supports that you suffered adverse consequences at work BECAUSE you sought advice, made a report of wrongdoing, or cooperated with an investigation? *

7. Have you reported the reprisal to anyone else, such as your employer or your union?*

If you have already reported it, please describe:

when you reported the reprisal
who you reported the reprisal to
the response you received and any ongoing proceedings

Evidence

8. Please attach any documents, records, correspondence, recordings or other evidence that you have in your possession related to the reprisal complaint and any previous reports of the allegation you have made.

You may upload up to 3 files Maximum file size limit is 5 MB Accepted file formats: pdf, doc, docx, txt, jpg, png Please retain the files that you upload for your own records

Please attach any documents

Drop files here or

Accepted file types: jpg, jpeg, gif, png, doc, docx, txt, pdf, Max. file size: 15 MB, Max. files: 3.

TEST Form Title (required element)