Barclay College

Anonymous Whistleblower Report Form

Confidential report

This form may be submitted anonymously. Do not include your name or identifying information unless you wish to be contacted for follow-up.

1. Incident Details

Date(s) of Incident Time(s) of Incident Location of Incident

2. Individuals Involved

Please list names, job titles, departments, or descriptions of the individuals involved, if known.

3. Type of Concern

Please select all that apply.

Other

4. Detailed Description of Concern

Please describe what happened, how you became aware of the issue, who was involved, whether the issue is ongoing, and any relevant dates, times, or locations.

5. Witnesses or Evidence

Witnesses Documents, emails, photos, recordings, or other evidence

6. Prior Reporting

Has this concern been reported previously?

Yes No Unknown

If yes, provide details if known

7. Optional Follow-Up Information

Leave these fields blank to remain anonymous.

Phone Email

Good Faith Statement

Reports should be made in good faith. Intentionally false accusations or misleading information may result in disciplinary or legal consequences.

Date Submitted:

Complete the security check to submit.