Whistleblowing Form – Lemonilo | Governance

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Whistleblowing Report Form

Reports may be submitted with the whistleblower’s personal information or anonymously. We assure the strict confidentiality of any personal data provided.

Whistleblower Disclosure *Do you wish to disclose your identity?AnonymousFull

Whistleblower Name *Reporter/Whistleblower Name

Email AddressWhistleblower Email Address

Phone Number *Whistleblower Phone Number

Whistleblower Relationship *RelationshipEmployeeVendorCustomerOther

Reported Party Name *Please identify the person involved/The Party Being Reported

Reported Party Business Unit/CompanyPlease identify the person involved Business Unit/Company

Incident Type *Incident TypeFraudConflict of InterestCode of ConductRegulatory Breach

Incident Location *Location where the incident occurred

Incident Time *Time where the incident occurred

Incident Details *Details

Incident RepetitionDo you think this problem occurred before?

Witness *Is there any witness in the incident?

Incident Escalation to Appropriate Channel or Individual *Has the issue been reported to the appropriate channels or individuals? If yes, to whom?YesNo

Explain

Incident Escalation to Local Authorities *Has the problem been reported to local authorities?YesNo

Threat (If any) *Did you get any threats? If yes, please elaborate.YesNo

Explain

EvidenceMaximum 20MB (Photo, Video, Audio, Document, Compressed File)

Drag and Drop (or) Choose Files

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