WHISTLEBLOWER REPORT FORM

REPORTER’S CONTACT INFORMATION
(This section may be left blank if the reporter wish to remain anonymous)
Name
Prefix First Last
Designation
Department
Contact No
Email Address
SUSPECT’S INFORMATION
Name*
Prefix First Last
Designation
Department
Contact No
Email Address
WITNESSES' INFORMATION (if any)
Name
Prefix First Last
Designation
Department
Contact No
Email Address
DISCLOSURE
- Please include (i) background and history of concern (What, Who, When, Where, How) and (ii) evidence (if any) to support the claim. - Insufficient details in the whistleblowing report may delay the investigation and outcome of the concerns raised.
Details*
Evidence / Supporting Document(s)
File 1
(Not more than 2MB)
File 2
(Not more than 2MB)
File 3
(Not more than 2MB)
Consent*
I hereby declare that all the information given herein are made voluntarily and true to the best of my knowledge. Institut Jantung Negara (IJN) Sdn. Bhd. will use the information and material(s) provided in the course of managing the disclosure/complaint

REPORTER’S CONTACT INFORMATION