Faculty of Health Sciences

Form for the reporting of possible research misconduct, fraud, maladministration, or non-adherence to approved research procedures, guidelines or policies

CONTACT INFORMATION OF THE WISTLEBLOWER

Name of the person seeking action:

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Status:

Current employee	☒
Current student	☐
Other	☐	If “Other”, please click here to specify.

Contact information:

Home or postal address:	Click here to enter text.
Telephone numbers:	Click here to enter text.
Home:	Click here to enter text.
Office:	Click here to enter text.
Cell:	Click here to enter text.
E-mail address:	Click here to enter text.

Department/Unit:

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Campus:

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DETAILS OF DISCLOSURE

Please identify the person:

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Research entity involved:

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Please identify the type of wrongdoing you are alleging (check one or all of the boxes)

Misconduct (mark one or more of the following three items if applicable)	☐
fabrication (making up research data or results and recording or reporting the fabricated material)	☐
falsification (manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research records)	☐
plagiarism (the appropriation of another person’s ideas, processes, results, or words without giving appropriate credit)	☐
Fraud	☐
Maladministration	☐
Non-adherence to approved research procedures, guidelines or policies.	☐

Please describe in detail of what you are disclosing (be as specific as possible. Also please attach any documents that might support your disclosure).

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CERTIFICATION AND SIGNATURE

I certify that all of the statements made in this allegation are true and correct to the best of my knowledge and belief.

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Signature	Click here to enter name.	Date

Original details: (23239522) G:\My Drive\2.2.4_SOPs_HSEthics\2.2.4_SOP_Ethics_1.8_SOP_for_Whistleblowing_Reporting_Form.docm
25 June 2018

File reference: 2.2.4