Onboarding Form

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Onboarding Form

If you need help whistleblowing, please fill in our support form below or you can download and email it to info@whistleblowerhouse.org. The details shared will be handled with the utmost sensitivity.
Please do not submit documents at this stage, The Whistleblower House will contact you requesting specific documents if and when required.

Personal information

Full Name and Surname *

Identity Number *

Residential Address (Optional)

Information Relating to the Disclosure (‘Whistleblowing’)

Company / Organisation Involved:

Details of your Case:

The date on which you first disclosed the information regarding the improper conduct:

Current Employment Status: (Tick the Option Most Applicable)

Still employed at the same company / organisation
Resigned or was dismissed from company /organisation

Legal Information

Have any proceedings commenced in the CCMA, in the Labour Court or High Court in relation to your matter?

Which law firm represented you (if any)

Confirm whether you signed a power of attorney or mandate that is still binding?

Is there any documentation available regarding the disclosure made by you?

How Can we Assist?

What type of assistance do you require? (Tick the applicable options below)

I require advice on how to make a protected disclosure
I require legal advice from an Attorney
I am seeking security in respect of my personal safety and/or the safety of my family, because a protected disclosure was made by me
I require therapy or psychological trauma counselling
Unsure

Are you comfortable with one of our Attorneys, from our panel of Specialist Law Firms, contacting you directly?
If so, kindly provide your contact details below:

Mobile No.

Email Address

Alternative Contact Telephone Number:

Next of Kin Contact Telephone Number: (Please provide Full Name, Surname, and the Nature of the Relationship, as well as a Mobile Telephone Number)

Have you received any trauma counselling or engaged with a therapist for reasons related to the disclosure made by you?

Other information that you regard as relevant or important:

Date on which this form is being submitted:

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