Disclosure of Wrongdoing Form

This Disclosure of Wrongdoing Form is designed to assist you with providing information to Manitoba Ombudsman about a disclosure of wrongdoing in or relating to the public service. The information provided on this form will help facilitate review of the matter under the Public Interest Disclosure (Whistleblower Protection) Act.

Disclosures of wrongdoing under PIDA must be made in writing in one of the following ways:

Write a letter to our office explaining your disclosure of wrongdoing.
Print and fill out the Disclosure of Wrongdoing form. Mail or fax the form to us. The form is also available by calling our office.
A fillable PDF version of the form is also available (if the PDF file does not open in your browser, right click on the link, save the file to your computer and open it with Adobe Acrobat or Reader). Fill it out, save it, and send it to us by email at ombudsman@ombudsman.mb.ca or by mail or fax.
Submit your disclosure using our secure online form below (note that if you use our online form, you will still have to submit copies of any relevant documentation by mail, fax or in-person).

PLEASE NOTE: If you leave this page before clicking the submit button at the bottom, all of the information you entered in the form will be lost.

Last Name (Required)
First Name (Required)
Address (Required)
Postal Code (Required)
City (Required)
Daytime Phone Number (Required)
Other Number
Email Address
May a message be left at your daytime telephone number? (Required)
Yes
No

Type of Wrongdoing

The wrongdoing I wish to disclose relates to: (please check all that apply*)

an act or omission constituting an offence under an act of the legislature or the Parliament of Canada, or a regulation made under an act
an act or omission that creates a substantial and specific danger to 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 an employee
gross mismanagement, including of public funds or a public asset
knowingly directing or counselling a person to commit one or more of the wrongdoings described above

*If none of the above apply, the Public Interest Disclosure (Whistleblower Protection) Act may not apply. Please consider addressing the matter through other internal policies and procedures, or contact your designated officer or our office for guidance.

Disclosure Details

In the space below, please provide information about the wrongdoing and the person(s) alleged to have committed the wrongdoing. The following details are required, if known:

a description of the wrongdoing
the names of those responsible
when the wrongdoing occurred
indication whether the matter has already been reported and the response received

Description of the wrongdoing (Required)

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Disclosure of Wrongdoing Form

Type of Wrongdoing

Disclosure Details