INTERNAL WHISTLEBLOWER REPORT

Confidential Report of Suspected Misconduct

IMPORTANT NOTICES

CONFIDENTIALITY: This report will be treated as confidential to the extent permitted by law. Your identity will be protected to the maximum extent possible during any investigation.

NON-RETALIATION: Federal and state laws prohibit retaliation against employees who report suspected violations in good faith. If you experience any retaliation, report it immediately.

OPTIONAL STEP: For many federal whistleblower programs, internal reporting is optional and does not affect your ability to receive awards or protection. However, some companies offer internal reporting incentives.

SECTION 1: REPORTER INFORMATION

A. Identity Disclosure

☐ Identified Report - I am providing my identity

☐ Anonymous Report - I wish to remain anonymous

Note: Anonymous reports may be more difficult to investigate. Providing your identity allows for follow-up questions and keeps you informed of investigation progress.

B. Personal Information (For Identified Reports)

Full Name: _________________________________

Employee ID (if applicable): _________________________________

Position/Title: _________________________________

Department: _________________________________

Work Location: _________________________________

Contact Information:

Work Phone: _________________________________

Personal Phone: _________________________________

Work Email: _________________________________

Personal Email: _________________________________

Preferred Contact Method: ☐ Work Phone ☐ Personal Phone ☐ Work Email ☐ Personal Email

Best Times to Contact: _________________________________

Supervisor Name: _________________________________

Supervisor Title: _________________________________

C. Employment Details

Date of Hire: _________________________________

Employment Type:
☐ Full-time Employee
☐ Part-time Employee
☐ Contractor
☐ Temporary Worker
☐ Intern
☐ Former Employee (Last Day: _____________)
☐ Other: _________________________________

SECTION 2: REPORT SUBMISSION DETAILS

A. Submission Information

Date of This Report: _________________________________

Report Submitted To:

☐ Ethics Hotline
☐ Compliance Department
☐ Human Resources
☐ Legal Department
☐ Audit Committee
☐ Direct Supervisor
☐ Senior Management
☐ Other: _________________________________

Report Method:
☐ This Written Form
☐ Online Portal
☐ Phone Hotline
☐ Email
☐ In-Person Meeting
☐ Other: _________________________________

B. Hotline/Reference Information

Hotline Case Number (if applicable): _________________________________

Online Submission Confirmation Number: _________________________________

SECTION 3: NATURE OF CONCERN

A. Category of Misconduct

Primary Category (select one):

Financial/Accounting:
☐ Financial statement fraud
☐ Revenue recognition manipulation
☐ Expense misclassification
☐ Asset misappropriation
☐ Improper journal entries
☐ Internal control violations
☐ Audit interference

Fraud/Theft:
☐ Theft of company assets
☐ Embezzlement
☐ Expense report fraud
☐ Time/Payroll fraud
☐ Vendor/Procurement fraud
☐ Customer billing fraud
☐ Insurance fraud

Bribery/Corruption:
☐ Foreign bribery (FCPA)
☐ Domestic bribery
☐ Kickbacks
☐ Conflicts of interest
☐ Improper gifts/entertainment
☐ Pay-to-play violations

Securities Violations:
☐ Insider trading
☐ Market manipulation
☐ Disclosure failures
☐ SEC filing inaccuracies

Government Contract Fraud:
☐ False claims
☐ Overbilling
☐ Product substitution
☐ Cost mischarging
☐ Small business fraud

Regulatory Violations:
☐ Environmental violations
☐ Health/Safety violations
☐ Data privacy violations
☐ Licensing violations
☐ Other regulatory: _________________________________

Workplace Misconduct:
☐ Harassment/Discrimination
☐ Hostile work environment
☐ Wage/Hour violations
☐ Unsafe working conditions
☐ Policy violations

☐ Other: _________________________________

B. Specific Laws/Regulations Potentially Violated

☐ Sarbanes-Oxley Act
☐ Dodd-Frank Act
☐ False Claims Act
☐ Foreign Corrupt Practices Act
☐ SEC Rules and Regulations
☐ OSHA Regulations
☐ Environmental Laws
☐ Company Policies
☐ Other: _________________________________

SECTION 4: DETAILED DESCRIPTION OF MISCONDUCT

A. Summary

Provide a brief summary of the suspected misconduct (2-3 sentences):

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

B. Detailed Narrative

Describe the misconduct in detail:

Include: What happened? Who was involved? When did it occur? Where did it occur? How was it done? Why do you believe it is wrong?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

C. Individuals Involved

List all individuals you believe are involved in the misconduct:

D. Timeline

When did the misconduct occur?

☐ Single incident - Date: _________________________________
☐ Multiple incidents - Date range: __________ to __________
☐ Ongoing - Started approximately: _________________________________

Detailed Timeline:

E. Location

Where did the misconduct occur?

Office/Facility: _________________________________

Department: _________________________________

Address: _________________________________

☐ Remote/Virtual
☐ Multiple Locations

SECTION 5: EVIDENCE AND DOCUMENTATION

A. Documentary Evidence

Do you have documents or records related to this report?
☐ No
☐ Yes

If yes, list documents:

Are you attaching documents to this report?
☐ No
☐ Yes - Number of attachments: _________

B. Electronic Evidence

Is there electronic evidence (emails, databases, recordings)?
☐ No
☐ Yes

If yes, describe:

_____________________________________________________________________________

_____________________________________________________________________________

C. Physical Evidence

Is there physical evidence?
☐ No
☐ Yes

If yes, describe and provide location:

_____________________________________________________________________________

SECTION 6: WITNESSES

A. Witnesses with Direct Knowledge

B. Others Who May Have Information

SECTION 7: YOUR KNOWLEDGE AND INVOLVEMENT

A. How You Learned of This Matter

☐ Direct observation
☐ Overheard conversation
☐ Told by another employee
☐ Reviewed documents
☐ Part of my job duties
☐ Other: _________________________________

Describe how you became aware of this matter:

_____________________________________________________________________________

_____________________________________________________________________________

B. Your Involvement

Were you asked to participate in the misconduct?
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

Did you participate in the misconduct?
☐ No
☐ Yes - Describe your role:

_____________________________________________________________________________

Did you benefit from the misconduct?
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

SECTION 8: PRIOR REPORTING

A. Internal Reports

Have you reported this matter previously?
☐ No
☐ Yes

If yes:

To Whom: _________________________________

Date: _________________________________

Method: _________________________________

Response Received:

_____________________________________________________________________________

B. External Reports

Have you reported this matter to any external party?
☐ No
☐ Yes

If yes:

Agency/Entity: _________________________________

Date: _________________________________

Reference Number: _________________________________

SECTION 9: IMPACT ASSESSMENT

A. Financial Impact

Estimated financial harm (if known):

To Company: $__________________

To Investors/Shareholders: $__________________

To Government: $__________________

To Customers: $__________________

B. Other Impacts

Safety concerns:
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

Regulatory exposure:
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

Reputational risk:
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

SECTION 10: MANAGEMENT AWARENESS

Do you believe management is aware of this misconduct?

☐ No - Management appears unaware
☐ Possibly - Some indication they may know
☐ Yes - Management appears to know
☐ Management is directly involved

Explain basis for your belief:

_____________________________________________________________________________

_____________________________________________________________________________

SECTION 11: SUGGESTED ACTIONS

What action do you believe the company should take?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

SECTION 12: RETALIATION CONCERNS

A. Current Status

Have you experienced any retaliation for raising this concern?
☐ No
☐ Yes

If yes, describe:

Type of Retaliation: _________________________________

Date(s): _________________________________

By Whom: _________________________________

Details:

_____________________________________________________________________________

B. Future Concerns

Do you have concerns about potential retaliation?
☐ No
☐ Yes - Describe:

_____________________________________________________________________________

C. Protective Measures Requested

☐ Request to maintain confidentiality of identity
☐ Request to limit who is informed of this report
☐ Request not to contact certain individuals
☐ Other: _________________________________

SECTION 13: CERTIFICATION

I certify that:

☐ The information I have provided is true and accurate to the best of my knowledge.

☐ I am reporting this matter in good faith because I believe the conduct described may be improper or illegal.

☐ I understand that knowingly making a false report may result in disciplinary action.

☐ I understand the company's non-retaliation policy and will report any retaliation I experience.

☐ I agree to cooperate with any investigation of this matter.

☐ I understand that I may also have the right to report this matter to government authorities.

For Identified Reports:

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

For Anonymous Reports:

Date of Submission: _________________________________

Anonymous Identifier (for follow-up): _________________________________

STATE-SPECIFIC NOTES

California

California Labor Code § 1102.5 provides broad protections for employees who report violations of state or federal law. As of January 1, 2025, employers must post a whistleblower rights notice. California law protects both internal and external reports. Employees should document all internal reports carefully.

New York

New York Labor Law § 740 (as amended 2022) protects employees who disclose or threaten to disclose activities that violate any law, rule, or regulation. Employees are encouraged but not required to report internally first. The statute protects disclosures to supervisors or to public bodies.

Texas

The Texas Whistleblower Act only protects public employees. Private sector employees in Texas should carefully consider whether internal reporting is advantageous before making external reports. Documentation of internal reports is especially important given limited state protections.

Florida

Florida Whistleblower Act (Fla. Stat. § 448.102) covers private employers with 10+ employees (expanded July 1, 2025). The law protects employees who disclose violations of laws, rules, or regulations. Public employees have additional protections under Fla. Stat. § 112.3187.

COMPANY INVESTIGATION PROCESS

Typical investigation steps:

1. Receipt & Acknowledgment: Report received and assigned
2. Initial Assessment: Preliminary review of allegations
3. Investigation Plan: Scope and methodology determined
4. Evidence Gathering: Documents collected, interviews conducted
5. Analysis: Evidence reviewed and analyzed
6. Findings: Conclusions reached
7. Remediation: Corrective actions implemented
8. Closure: Reporter notified of outcome (to extent permitted)

Your Rights During Investigation:

• Right to be free from retaliation
• Right to reasonable confidentiality
• Right to report to government if dissatisfied with internal response
• Right to consult with personal legal counsel

YOUR OPTIONS AFTER INTERNAL REPORTING

☐ Wait for internal investigation results
☐ Consult with an attorney about external reporting options
☐ Report to government agency (SEC, OSHA, DOJ, etc.)
☐ File a qui tam action (for government fraud)

Remember: For most federal whistleblower award programs (SEC, CFTC, etc.), you can report directly to the government without first reporting internally. Internal reporting is generally optional but may affect award percentages in some programs.

DOCUMENT RETENTION

Keep copies of:
☐ This report
☐ All attachments
☐ Any acknowledgment or case number received
☐ Any correspondence about this report
☐ Notes of any meetings about this report
☐ Evidence of any retaliation

Store copies securely outside of company systems.

CONTACT INFORMATION

Ethics Hotline: _________________________________

Compliance Officer: _________________________________

General Counsel: _________________________________

Human Resources: _________________________________

Audit Committee Chair: _________________________________

This template is provided for educational purposes only and does not constitute legal advice. Internal reporting is one option available to whistleblowers but may not be required depending on the applicable law. Consult with an attorney to understand your rights and the best approach for your specific situation.