KPMG Ethics Line

1.1 About which company would you like to make this report?

Company name:

1.2 Where is the company located?

Department / Section:
Address:
City:
Province:
Country:

1.3 Please indicate your relationship to the company reported.

Contractor
Customer
Employee
Supplier
Other

Please specify:

1.4 Would you like to provide your name?

I would like to provide my name and contact information.
I would like to remain anonymous.

Name:
Contact information:

2.1 Please select the applicable Incident Type from the list below that best describes the issue(s) you are reporting:

Fraud (including: forgery, falsification of documents/claims, identity theft)
Misconduct (including: sexual harassment, any form of discrimination, poor time-keeping, intimidation, abuse/misuse of company property)
Unethical Behaviour (including: favouritism, nepotism, transgression of company policies, conflicts of interest)
Theft
Corruption (including: any form of bribery, third party collusion)
Other

Please specify:

3.1 Do you know the name of the person(s) or organisation(s) involved?

Yes
No

Name(s):

3.2 Do you want to add another involved party?

Yes
No

If yes, please provide name?

3.3 Has management been notified?

Yes
No

Please provide the name of the person/s notified.

First name
Last name
Title
What date was the individual notified?	YYYY-MM-DD

4.1 When did the incident occur?

YYYY-MM-DD

4.2 Where did this incident occur?

4.3 How do you know about this incident?

4.4 Is any supporting information available? If you have any physical documentation available you can upload the file(s) here - please provide a description of the uploaded documentation below.

4.5 Please provide a detailed description of the incident. Provide as much detail as you are able to, using times, dates, places and names whenever possible. Indicate WHO did it? WHAT did the person do? WHERE did the person do it? WHEN did the person do it? HOW did the person do it? You can copy and paste the information from Word or any text editor by selecting the text, pressing Ctrl-C, and then selecting the box and pressing Ctrl-V. Please note that this field is limited to 5,000 characters.

4.6 Do you know whether this incident will reoccur:

Yes, it will occur again in the next 24 hours
Yes, but after 24 hours
No, it will not occur again, or I don't know

5.1 Please indicate how you found this site:

Found using a search engine
Followed a link from another page
Saw a post in an online newsgroup
Word of mouth (referred by a friend)
Read about it in print media
Don't remember
Other

Please specify: