Disclosure Form for Members of the Royal Canadian Mounted Police (RCMP)

(Microsoft Word Version - 263 K)

Submit completed forms by mail, fax or in person to:

Office of the Public Sector Integrity Commissioner of Canada 
60 Queen Street, 4^th Floor 
Ottawa, Ontario  K1P 5Y7

613-941-6400 or 1-866-941-6400 (toll-free) 
Fax: 613-946-2151 (not a secure means of transmission)

(A) General Contact Information

Name: 
Title or Rank (optional) 
Current organization if other than RCMP 
Division Branch or Unit 
Address where you would like to be contacted 
Telephone number(s) at which you would like to be contacted 
Fax (optional) 
E-mail (optional)

(1) Are you represented by someone (e.g., legal counsel, Divisional Staff Relations Program representative or other)?

No 
Yes 
Please provide name, title and contact information for your representative

(2) Do you want the Office of the Public Sector Integrity Commissioner to contact you directly or through your representative? (choose one of the following)

Through my representative 
Contact me directly

Correspondence (choose one of the following)

Send correspondence to my representative as well as to me 
Do not send correspondence to my representative but only to me

(B) Information about your Disclosure of Wrongdoing

(1) Please identify the wrongdoing that has been committed or that is ongoing:

Definition of wrongdoing (choose applicable section(s))

8. The Public Servants Disclosure Protection Act (the Act) applies in respect of the following wrongdoings in or relating to the public sector:

(a) a contravention of any Act of Parliament or of the legislature of a province, or of any regulations made under any such Act, other than a contravention of section 19 of this Act; 
(b) a misuse of public funds or a public asset; 
(c) a gross mismanagement in the public sector; 
(d) an act or omission that creates a substantial and specific danger to the life, health or safety of persons, or to the environment, other than a danger that is inherent in the performance of the duties or functions of a public servant; 
(e) a serious breach of a code of conduct established under section 5 or 6; and 
(f) knowingly directing or counselling a person to commit a wrongdoing set out in any of paragraphs (a) to (e).

(2) Please provide a description of the wrongdoing. Identify any applicable acts or regulations, policies or directives relating to the wrongdoing:

(Attach supporting documentation or use appendix if necessary.)

(3) Please identify the location where the wrongdoing took place:

(4)  Please identify the date(s) on which the wrongdoing occurred or whether it is ongoing:

(5) Please identify the person(s) alleged to be responsible for the wrongdoing:

1. Name 
Employer 
Work address 
Telephone number(s) 
Fax (optional) 
E-mail (optional)

2. Name 
Employer 
Work address 
Telephone number(s) 
Fax (optional) 
E-mail (optional)

3. Name 
Employer 
Work address 
Telephone number(s) 
Fax (optional) 
E-mail (optional) 
(use appendix if necessary)

(C) Other Proceedings

Explanatory Notes:

Subsection 23(1) of the Act provides that the Commissioner may not deal with a disclosure or commence an investigation if a person or body acting under another Act of Parliament is dealing with the subject-matter of the disclosure or the investigation other than as a law enforcement authority. The RCMP is not deemed a law enforcement authority when conducting an investigation under Part IV or V of the Royal Canadian Mounted Police Act.

Paragraph 24(1)(a) of the Act provides that the Commissioner may refuse to deal with a disclosure or to commence an investigation – and he or she may cease an investigation – if he or she is of the opinion that the subject-matter of the disclosure or the investigation has been adequately dealt with, or could more appropriately be dealt with, according to a procedure provided for under another Act of Parliament;

Subsection 24(2) of the Act provides that the Commissioner must refuse to deal with a disclosure or to commence an investigation if he or she is of the opinion that the subject-matter of the disclosure or the investigation relates solely to a decision that was made in the exercise of an adjudicative function under an Act of Parliament, including a decision of the Commissioner of the RCMP under Part IV or V of the Royal Canadian Mounted Police Act.

(1) Have you reported this alleged wrongdoing to a supervisor or to any other person in the RCMP?

No 
Yes - Please identify the person to whom you made the report, provide relevant dates and describe any actions or decisions taken as a result of your report:

(Attach supporting documentation or use appendix if necessary.)

(2) Is the subject-matter of this disclosure of wrongdoing currently being dealt with by the RCMP pursuant to Part IV or V of the RCMP Act or RCMP Regulations?

Unknown 
No 
Yes – Please provide details

(Attach supporting documentation or use appendix if necessary)

(3) Have you reported this alleged wrongdoing to another person or body, outside of the RCMP, acting under another Act of Parliament?

No 
Yes - Please identify the person or body to whom you made the report, provide relevant dates and describe any actions or decisions taken as a result of your report:

(Attach supporting documentation or use appendix if necessary.)

(4)  Is the subject-matter of this disclosure of wrongdoing currently being dealt with or has it been dealt with by another person or body, other than the RCMP, pursuant to another Act of Parliament?

Unknown 
No 
Yes – Please provide details

(Attach supporting documentation or use appendix if necessary)

(D) Declaration

I make this disclosure in good faith and I declare that all of the information provided is true and accurate to the best of my knowledge.

I understand that it is my responsibility to provide the Commissioner with all of the information required by this form, and to attach to this form any relevant documentation.

Signature

Date

Note:

By submitting the Disclosure Form, you are authorizing the Office of the Public Sector Integrity Commissioner to collect your personal information.

This information is being collected solely for purposes related to the application of the Public Servants Disclosure Protection Act. Accordingly, an analyst / investigator from the Commissioner’s Office may contact you for further information.

The disclosure process is confidential. Your identity and other information provided to the Office of the Public Sector Integrity Commissioner when making in good faith a disclosure about a wrongdoing will be protected to the extent possible under applicable laws. Such information obtained or created by the Office of the Public Sector Integrity Commissioner in the course of an investigation into a disclosure cannot be released under the Access to Information Act or the Privacy Act or the Personal Information Protection and Electronic Documents Act. This information is held in Personal Information Bank PSIC PPU 005 and you have a right to access this information in accordance with the Privacy Act.