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WHISTLEBLOWER REPORT ONLINE FORM
REPORTER’S CONTACT INFORMATION
(This section may be left blank if the reporter wish to remain anonymous)
Name
Salutation
Dr.
Dato
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First
Last
Designation
Department
Contact No
Email Address
SUSPECT’S INFORMATION
Name
*
Salutation
Dr.
Dato
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First
Last
Designation
Department
Contact No
Email Address
WITNESSES' INFORMATION (if any)
Name
Salutation
Dr.
Dato
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
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Last
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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
*
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File 2
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File 3
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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
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