Reprisal Complaint Form

This Complaint of Reprisal Form is designed to assist you with providing information to Manitoba Ombudsman about reprisal being taken against you for seeking advice about making a disclosure, making a disclosure or co-operating in an investigation under the Public Interest Disclosure (Whistleblower Protection) Act (PIDA). The information provided on this form will help facilitate review of the matter under PIDA.

Complaints about reprisal under PIDA must be made in writing in one of the following ways:

Write a letter to our office explaining your complaint about reprisal.
Print and fill out the Complaint of Reprisal 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 complaint 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

Reprisal Details

I believe the following measure(s) have been taken against me because I have, in good faith, sought advice about making a disclosure, made a disclosure or co-operated in an investigation under PIDA:

a disciplinary action
a demotion
termination of employment
a measure that adversely affects my employment or working conditions
a threat to take any of the above measures

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.

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

the date(s) on which you sought advice about making a disclosure, made a disclosure or co-operated in a PIDA investigation
the person you sought advice from, made a disclosure to, or who obtained your cooperation in an investigation, including their name and position
a description and timeline of the reprisal
the names and positions of those responsible for the reprisal

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Reprisal Complaint Form

Reprisal Details