A whistleblower complaint form is used to make a protected disclosure about serious wrongdoing, such as fraud, financial misstatement, legal violations, safety cover-ups or abuse of authority, through the company's vigil mechanism. It protects the whistleblower's identity and goes to a designated vigilance officer or audit committee.
This disclosure is made under the company's Whistleblower / Vigil Mechanism Policy. Mark the envelope 'Protected Disclosure – Confidential' or email [Vigilance Email]. Your identity will be protected.
1. Whistleblower Details (kept separately and confidential)
Name
Employee ID
Designation / Department
Safe contact
I wish to remain anonymous (Yes / No)
2. Nature of Wrongdoing
Financial fraud or misappropriation
Manipulation of accounts or records
Violation of law or regulation
Falsification of safety, quality or test data
Abuse of authority
Leak of confidential or price-sensitive information
Other serious wrongdoing
3. Particulars
Persons involved (name, designation)
Period of wrongdoing
Location / business unit
Detailed facts
Approximate amount involved (₹ [Amount])
Evidence available (description, location)
Has this been reported elsewhere? Details
4. Safeguards
Your identity will be known only to the Vigilance Officer and, where needed, the Audit Committee.
You will not face dismissal, demotion, transfer, harassment or any other unfair treatment for making this disclosure in good faith.
You should not investigate on your own or access records you are not authorised to see.
You may report any victimisation directly to the Audit Committee Chairperson.
5. Declaration
I make this disclosure in good faith and reasonably believe the information to be true. I understand the matter will be examined confidentially and impartially.
Addressed to the vigilance officer or audit committee chair
Nature of wrongdoing
Persons involved, including seniority
Facts and evidence with dates
Whether the matter has been reported elsewhere
Identity protection and anonymity choice
Safeguards against victimisation
When to use it
An employee suspects financial fraud, siphoning of funds or manipulation of accounts
Safety or quality test results are being falsified
Senior management is suspected of abuse of authority or legal violations
Normal reporting lines are compromised and an independent channel is needed
How to customise this template
1Insert your vigilance officer's name and the audit committee chair's contact
2Add the reference to your whistleblower or vigil mechanism policy
3Provide a sealed envelope or secure email option
4Explain how anonymous reporters can check status using a reference number
5Translate for factory and field staff
HR tips
Keep the whistleblower's identity separate from the case file
Never ask the whistleblower to prove the allegation; reasonable belief is enough to report
Escalate disclosures involving the vigilance officer or directors to the audit committee
Monitor the whistleblower for signs of victimisation for a period after the case
This template is a starting point. Listed companies and certain other companies must have a vigil mechanism under company law and listing rules; review this form with your compliance team and a legal adviser.
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This form is used to report conduct that you believe breaches company rules or the code of conduct. All complaints are treated confidentially. If your complaint relates to sexual harassment, please approach the Internal Committee directly as per the company's POSH policy.
1. Complainant Details
Employee Name
Employee ID
Designation
Department
Work Location
Contact Number
Preferred mode of contact
2. Person(s) Complained Against
Name
Designation / Role
Department or Organisation (if vendor/customer)
Relationship to you (colleague, supervisor, vendor, other)
Anyone working at this site may use this form. You may give your name or leave it blank. For complaints of sexual harassment please contact the Internal Committee: [IC Presiding Officer Name], [Phone].
Use this form to report a suspected breach of the Code of Conduct. You may remain anonymous. Submit to [Ethics Email] or the sealed ethics box at [Location]. Sexual harassment complaints should be made to the Internal Committee.