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PUBLIC INTEREST DISCLOSURE FORM
Date of Disclosure (You must specify a value for this required field)
+
Name of Discloser
(Please enter name of person making disclosure. NOTE: Disclosure may be made anonymously. )
Address of Discloser
(Please enter the street adddress, suburb, state and postcode of discloser)
Street Address
Suburb
State
Post Code
Phone Number of Discloser
Email Address of Discloser
Description of Disclosure
Is your disclosure about:
Substantial and specific danger to health and safety of a person with a disability
Substantial and specific danger to the environment
Reprisal in connection with a PID
Corrupt conduct
Maladministration that adversely affects a person’s interest in a substantial and specific way
A substantial misuse of public resources
Substantial and specific danger to public health or safety
Please provide further details:
Council officers/Councillors (Name)
(Please enter name any of any council officers or councillors that you believe to have an involvement in the disclosure.)
Council officers/Councillors (Address)
(Please enter address of any council officers or councillors that you believe to have an involvement in the disclosure.)
Council officers/Councillors (Phone No.)
(Please enter phone number of any council officers or councillors that you believe to have an involvement in the disclosure.)
Council officers/Councillors Email Address
(Please enter the email address of any council officers or councillors that you believe to have an involvement in the disclosure.)
Date/s of disclosed conduct
(Provide the dates on which you believe
the conduct disclosed occurred.)
Location
(State the location at which the conduct
disclosed occurred.)
Witness 1 (Name)
(State the full name of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed.)
Witness 1 (Address)
(State the address of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed.)
Witness 1 (Phone No) (State the phone number of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed.)
Witness 1 Email Address
(State the email address of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed. )
Witness 1 (Witness) What did the person witness?
Do you wish to enter another witness?
Yes
No
Witness 2 (Name)
(State the full name of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed.)
Witness 2 (Address)
(State the address of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed.)
Witness 2 (Phone No) (State the phone number of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed.)
Witness 2 Email Address
(State the email address of any witnesses to the conduct disclosed or who may be able to verify the conduct you have disclosed. )
Witness 2 (Witness) What did the person witness?
Documentary Evidence
State the nature of any documents or written material that supports your claim or that you have seen but cannot produce.
Other Evidence
State the nature of any other evidence that supports your claim.
Reported
Have you reported this information to any other person or agency?
Yes
No
Please provide details
If you have any documents you can attach them here. (There is a limit of 20 MB per file)
Do you wish to upload another file?
Yes
No
If you have any documents you can attach them here. (There is a limit of 20 MB per file)
Do you wish to upload another file?
Yes
No
If you have any documents you can attach them here. (There is a limit of 20 MB per file)
Do you wish to upload another file?
Yes
No
If you have any documents you can attach them here. (There is a limit of 20 MB per file)
Do you wish to upload another file?
Yes
No
If you have any documents you can attach them here. (There is a limit of 20 MB per file)