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This form is to be used by persons wishing to make a disclosure as per the Public Interest Disclosure Act 2003 (PID Act). The City of Joondalup strongly encourages anyone thinking about making a public interest disclosure to seek out a nominated proper authority (Public Interest Disclosure Officer) to discuss their issues first. Please call one of the City’s Public Interest Disclosure Officers on 9400 4433, 9400 4370. It is essential that you ensure you understand your rights and responsibilities under the PID Act before you submit this lodgement form. You may wish to seek external legal advice about those rights and responsibilities.

Personal Details

Name

First Name Surname

Title

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Mobile

I wish to make an anonymous public interest disclosure. I understand that:

• I will not receive any information about what happens to this disclosure.
• It may be more difficult for the proper authority to look into the matter(s) as they cannot come back to me for further information.
• It may be more difficult for the proper authority/public authority to protect me.
• This anonymous disclosure may not prevent me from being identified during any investigation or when action is being taken.

Yes

Categories of Public Interest Information*

Improper conduct

An offence under written State law

Substantial unauthorised or irregular use of, or substantial mismanagement of, public resources

Conduct involving a substantial and specific risk of injury to public health, or prejudice to public safety or harm to the environment

Administration matter(s) affecting you personally

Disclosure Details

Do you work for a public authority?*

Yes

Rather not say

If yes, which public authority and what is your position title

Does the disclosure relate to one or more individuals?*

Yes

If yes, provide name(s) and position(s) held by person(s) in the public authority

When did the alleged events occur?

Summary of the matters to disclose*

Additional Information

Description of any documents provided or names of witnesses

Supporting documents

Have you reported this information to any other person or agency?*

Yes

If yes, did you report this information as a Public Interest Disclosure matter?*

Yes

If yes, please provide details

Acknowledgement

I believe on reasonable grounds that the information contained in this disclosure is or may be true and I am aware that:

• I will commit an offence under section 24 of the PID Act, if I know that the information contained in this disclosure is false or misleading in a material particular, or I am reckless as to whether it is false or misleading in a material particular.
Penalty: $12 000 or imprisonment for one (1) year.

• I will forfeit the protection provided by section 13 of the PID Act, if I fail, without reasonable excuse, to assist a person investigating the matter by supplying requested information (s17).

• I will forfeit the protection provided by section 13 of the PID Act, if I subsequently disclose this information to any person other than a proper authority under the PID Act (s17).

• I will commit an offence, if I subsequently make a disclosure of information that might identify or tend to identify anyone as a person in respect of whom this disclosure has been made under the PID Act, except in accordance with section 16(3) of the PID Act. Penalty: $24 000 or imprisonment for two (2) years.

• I cannot withdraw my disclosure after I have made it.

The City of Joondalup strongly encourages anyone thinking about making a public interest disclosure to seek out a nominated proper authority (Public Interest Disclosure Officer) to discuss their issues first. Please call one of the City’s Public Interest Disclosure Officers on 9400 4433, 9400 4370 or 9400 4399.

Phone

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