1 How are you associated with the company?

Employee
Vendor/supplier
Director
Other

1.1 Please specify:

2 Your details:

I would like to share my name and contact information
I would like to share my information with KPMG, but not with the company

2.1 Name:

2.2 Contact number:

3 Please select the applicable incident type(s) from the list below that best describes the issue(s) you are reporting. Please note that multiple issues can be selected

Acceptance of gifts and entertainment
Acceptance of kickbacks
Breach of Company policies
Bribery and corruption
Child labour
Claiming of false expenses in reimbursement
Concurrent employment
Conflict of interest
Discrimination
Favouritism
Financial fraud of any nature
Fraud in request for proposal or request for quotation
Harassment of any nature other than sexual harassment
Inappropriate use of social media
Misappropriation of Company assets or resources
Misuse of Company confidential information
Misrepresentation of Company’s financial books and records
Misuse of Company name or logo
Misuse of authority
Procurement fraud
Sexual harassment
Substance abuse
Unfair trade practices and/ or anti-competitive behaviour
Victimization or bullying
Violation of any laws or regulations applicable to the Company
Violation of human rights
Violation of the environment, health and safety guidelines
Others

3.1 Please specify:

4 Please provide name, designation and department of the person(s) involved?

Name Designation Department

Individual 1

Individual 2

Individual 3

Individual 4

5 When did the incident occur?

(Please provide tentative date if you do not know the exact date)

6 Please confirm the location of the incident

7 How did you find out about this incident?

8 How long has this been occurring for?

Less than a month
1 - 6 months
6 - 12 months
Greater than 12 months

8.1 Please specify:

9 Please provide a detailed description of the incident. To enable your company to act on your complaint, you are requested to provide specific information where possible including names, location, date, time etc. Please note that this field is limited to 5,000 characters.

10 Do you have any evidence in support of your allegations?

Yes
No

10.1 If yes, please provide details of the evidence:

10.2 Please attach the evidence:

(Maximum file size is 500 KB)

(Allowed files - .zip, .doc, .docx, .pdf, .jpg, .png)

(Please zip the files for multiple attachments)

11 Is anyone else aware of this incident?
Yes
No

Name Designation Department

Individual 1

Individual 2

Individual 3

Individual 4

12 Is there any additional information that would facilitate the investigation of this matter?

Yes
No

12.1 If yes, please provide detail:

13 Have you reported this incident to anyone in the company?

Yes
No

Name Designation Date

Individual 1

Individual 2

Individual 3

Individual 4

Please send a copy of complaint to my email address

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