Documents

Policies, Regulations Forms and Bylaws

6730 Form | Public Interest Disclosure Policy - Disclosure Form

Date Approved: October 23 2023
Date Reviewed/Amended:

INSTRUCTIONS

Before filling out this Public Interest Disclosure Form, please review the School District’s Public Interest Disclosure Policy and Procedures 6730.  www.rupertschools.ca/----. Please also ensure that you provide all required details and attach copies of any documents you wish to submit as part of your report. The completed form (together with all attachments) may be submitted by mail or email to hr@sd52.bc.ca or 634 6th Avenue East, Prince Rupert B.C. V8J 1X1.

PRIVACY STATEMENT

The personal information submitted in this Public Interest Disclosure Form is collected by the School District under sections 26(a) and (c) of the Freedom of Information and Protection of Privacy Act, and will be used to assess, review, investigate and respond to allegations of wrongdoing made under the Public Interest Disclosure Act. If you have any questions about the collection, use or disclosure of your personal information in connection with your disclosure, please contact the District Privacy Officer at hr@sd52.bc.ca, 634 6th Ave East or 250 624-6717.

CONFIDENTIALITY

Reports made under the Public Interest Disclosure Act are received and held in confidence by the School District. The reports and information received will be used and shared only to the extent reasonable and necessary to assess, investigate and respond to your disclosure and will not be used or disclosed for other purposes except as permitted or required under the Freedom of Information and Protection of Privacy Act and the Public Interest Disclosure Act or other applicable laws.

COMPLETING THE DISCLOSURE FORM

The purpose of this Public Interest Disclosure Form is to assist you in making a disclosure under the Public Interest Disclosure Act. The requested information is to ensure we have sufficient information to carefully review, investigate and respond to your disclosure. If you are unable to provide all requested details at the time you make your initial disclosure, you may ask to submit additional details at a later time.

DISCLOSURE REPORT

  1. Are you a current employee of the School District?

☐ Yes                    ☐ No

  1. Were you an employee of the School District when the alleged wrongdoing occurred or was discovered?

☐ Yes                    ☐ No

  1. Please enter your contact information below so that we can communicate with you about your disclosure. Your identity and contact information may be shared with investigators to allow them to communicate with you.

While anonymous disclosures may be accepted under the Public Interest Disclosure Act, we may not be able to investigate if we are unable to contact you to confirm you are a current or former employee or to obtain further details, evidence or clarification about your disclosure.

NAME

 

 

ADDRESS

 

 

EMAIL

 

 

PHONE

 

 

ADDITIONAL INSTRUCTIONS

e.g. How would you prefer to contacted? May we leave messages for you?

 

 

 

 

  1. A report may be made under the Public Interest Disclosure Act for any of the following categories of wrongdoing. Please check any that apply:

☐         serious act or omission that, if proven, would constitute an offence under an enactment of British Columbia or Canada;

☐         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 an employee's duties or functions;

☐         a serious misuse of public funds or public assets;

☐         gross or systemic mismanagement;

☐         knowingly directing or counselling a person to commit a wrongdoing described above.

If your report does not fall within one of these categories, you may wish to consider whether your report falls under another policy or procedure of the School District.  www.rupertschools.ca

  1. In the space below, please describe the alleged wrongdoing and the person(s) alleged to have committed the wrongdoing. Please provide as much detail as you are able, including:
  • A description of the wrongdoing and any relevant background,
  • The names of those responsible,
  • When and where the wrongdoing occurred,
  • Names of people who witnessed the wrongdoing, if available,
  • Any law or legislation that has been breached.

DESCRIPTION OF ALLEGED WRONGDOING

 

 

 

 

 
  1. Have you previously reported the wrongdoing to the School District?

☐ Yes                    ☐ No

If yes, please indicate who the report was made to and any actions taken.

REPORT DATE AND PERSON REPORTED TO

 

 

 

 

 
  1. Please describe any other steps or action that you or others have taken to address, report or prevent the reported wrongdoing.

OTHER ACTION TAKEN

 

 

 

 

 
  1. Do you know of any other organizations that are investigating the reported wrongdoing or whether other complaints or claims about the wrongdoing have been filed (e.g. court filings, grievance, human rights complaint, privacy complaint, police investigation, etc.). Please explain.

OTHER INVESTIGATIONS