Reprisal Complaint Form for Current and Former Public Sector Employees, including Members of the RCMP

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)

This form is only intended for current or former federal public servants making a complaint of reprisal following a protected disclosure or wrongdoing or participation in a related investigation.

Please respond to all questions to the best of your ability.  Contact the Office at 1-866-941-6400 if you require assistance. We strongly recommend you read through all questions prior to filling out this form.

General Contact Information

Name: 
Job title or Rank (RCMP): 
Current employer: 
Current Branch or unit: 
Address where you would like to be contacted (does not have to be your work address): 
Telephone number(s): 
Fax (optional): 
Official language of choice for correspondence: English   French 
Email*:

*NOTE:  The Office of the Public Sector Integrity Commissioner does not accept reprisal complaints or disclosures of wrongdoing via e-mail due to security and privacy concerns. The majority of communication between the Office and you will be undertaken via regular mail correspondence or by telephone. However, for increased convenience, correspondence regarding basic status update of files or setting up interviews may be sent by email.

Representation

Although not a requirement, some individuals may choose to be represented by someone to assist them in dealing with their disclosure.

1.  If you are represented (e.g., legal counsel, union representative or other), please provide their contact information.

Name:

Organization:

Email:

Title:

Telephone:

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

3.  Correspondence (choose one of the following)

Send correspondence to my representative as well as to me 
Send correspondence to me only 

Employment Status

Are you or were you: 
Currently employed in the public sector 
or 
Formerly employed in the public sector 
Name of Employer where reprisal(s) occurred:

Information about the Alleged Reprisal 

Under the Public Servants Disclosure Protection Act (the Act), a reprisal could include any of the following measures taken against a public servant because he or she has made a protected disclosure or cooperated in an investigation into a disclosure of wrongdoing:

• disciplinary measures;
• demotion;
• termination of employment, including a discharge or dismissal in the case of a member of the Royal Canadian Mounted Police;
• measures that adversely affect the employment or working conditions of the public servant;
• threatening to take any measures described above.

4.  In your own words, while keeping in mind the definition of reprisal, please describe what reprisal measures you believe were taken against you (broadly defined above). Include what the exact measures were, who is alleged to have taken them, as well as when (date) the measures were taken.

You may attach supporting documentation or additional information if necessary. To ensure a timely review of your case, please specify which portions of your documentation support your allegations.

5.  Please provide additional information about the person(s) alleged to be responsible for the reprisal(s).

Name:  

Title or Rank (RCMP): 

Federal Department/Organization:

Work Unit:

Work Telephone:

Work Address:

Name:  

Title or Rank (RCMP): 

Federal Department/Organization:

Work Unit:

Work Telephone:

Work Address:

For an action to be considered “reprisal” under the Act, the measure(s) you identified above must have been taken against you because you made a protected disclosure of wrongdoing or cooperated in a related investigation.

A protected disclosure concerning a wrongdoing can be made to:

• your supervisor; or
• the designated Senior Officer appointed in your organization under the Public Servants Disclosure Protection Act; or
• the Public Sector Integrity Commissioner.

A protected disclosure may also include wrongdoing allegations made:

• in the course of a Parliamentary proceeding;
• in the course of a procedure established under any other Act of Parliament; or
• when lawfully required to do so.

6.  Did you make a protected disclosure of wrongdoing or have you cooperated in an investigation?

Yes

No

If yes, please provide details, including relevant dates and names of the people to whom or the office to which you made a protected disclosure. If you made a disclosure of wrongdoing to our Office, you only need to include the PSIC file number (i.e. D2016-0000):

You may attach supporting documentation or additional information you deem relevant.

Time Limit

Time limit for filing a reprisal complaint:

Subsection 19.1(2) of the Public Servants Disclosure Protection Act provides that a reprisal complaint must be filed not later than 60 days after the day on which you knew, or in the Commissioner’s opinion ought to have known, that the reprisal was taken.

The Commissioner may extend the 60-day period to file a complaint if he believes that an extension is appropriate considering the circumstances of the complaint. For additional information, consult the Office’s Policy on the Time Limit for Making a Complaint of Reprisal at psic-ispc.gc.ca/en/resources/corporate-publications/time-limit-making-complaint-reprisal.

7.  Please indicate when you became aware of the reprisal(s), to the best of your recollection, and how you became aware:

8.  If you are filing your complaint outside the 60-day limitation period, please explain the reasons for the delay:

You may attach supporting documentation or additional information you deem relevant.

Other Proceedings

Restriction

According to the Public Servants Disclosure Protection Act, the Commissioner may not deal with a complaint if a person or body acting under another Act of Parliament or a collective agreement is dealing with the subject-matter of the complaint other than as a law enforcement authority (see Subsection 19.3(2) of the Act).

Commissioner’s Discretion

* Explanatory Notes

Commissioner’s Discretion

According to the Public Servants Disclosure Protection Act, the Commissioner may refuse to deal with a complaint if he is of the opinion that the subject-matter of the complaint has been adequately dealt with, or could more appropriately be dealt with, according to a procedure provided for under an Act of Parliament, other than this Act, or a collective agreement (see Subsection 19.3(1) of the Act).

9.  Have you filed a complaint with another person or body acting under another Act of Parliament, or under a collective agreement?

Yes

No

If you answered yes, indicate to whom or through which means you raised your concerns. Check all that apply.

Departmental Senior Officer for internal disclosure

Management

Grievance

Harassment complaint

Other formal complaint (Privacy Act, Access to Information Act, Human Rights complaint, etc.)

Other

For each option checked off above, answer the following questions and provide relevant documentation:

a. Has the matter been resolved? If yes, explain.

b. Is it ongoing? If yes, explain.

For regular and civilian members of the RCMP only:

10.  Does the subject-matter of the reprisal complaint concern an action under section 20.2 of the Royal Canadian Mounted Police Act, or any matter that is the subject of an investigation or proceeding under Part IV of the RCMP Act?

Yes

No

11. If you answered yes above, have you exhausted every procedure available to under Part IV of the Royal Canadian Mounted Police Act for dealing with the matter? If yes, your complaint must have been made within 60 days of the conclusion of any investigation or proceeding commenced under Part IV of the Royal Canadian Mounted Police Act.

Yes

No

Date when procedures were concluded:

(Attach any relevant documents such as letters, reports or decisions that explain the proceedings and how they were concluded.)

Declaration

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 Complaint 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, a representative from the Commissioner’s Office may contact you for further information.

The information is held under Personal Information Bank PSIC PPU 006 and you have a right to access this information in accordance with the Privacy Act.