The Whistleblower House

Sign Up as a Whistleblower

Please do not use company equipment or networks when submitting your application (e.g., email, computer, mobile phone, Wi-Fi).

Before completing the form, we recommend reading through our guidebooks to familiarise yourself with the whistleblowing process and The Whistleblower House’s services: Whistleblower Guidebooks

Subject *

First Name *

Last Name *

Title *

Primary Phone Number *

Alt Phone Number

Your Email *

Alt Email Address

ID Number *

ID Document *

Date of Birth *

Gender

Male

Female

Non-Binary

Transgender

Undisclosed

Home Language

Afrikaans

English

isiZulu

isiXhosa

isiNdebele

Sepedi

Sesotho

Setswana

siSwati

Tshivenda

Xitsonga

Other

Address Line 1

Address Line 2

City

Province

Country

Are you a person with a disability / impairment

Yes

Marital Status

Married

Never Married

Separated

Divorced

Widowed

Cohabitate

Number of Dependents

Highest Level of Education

Less than a high school degree

High school degree or equivalent

Higher Certificate

Graduate degree

Postgraduate degree

Religion

Christian

Islam

Hinduism

African Initiated Church

Judaism

Buddhism

Unaffiliated

Other

Next of Kin

Email Address

Phone Number

Relationship with WB

Your Current Position / Level in Company

Name of Organisation

Sector

Public

Private

Non-Profit

Industry

Referred by an organisation? If yes, which one?

Have you blown the whistle already? *

Whistleblower Incident Information

Was a Protected Disclosure made?

First Disclosure Date

Company/ Organisation Involved

Did you leave the company?

Yes

Case Details *

Have you been subjected to an occupational detriment?

Date of Occupational Detriment

Details of Occupational Detriment

Did you challenge the occupational detriment?

Yes

Details of challenge to occupational detriment

Have you appointed legal representation?

Yes

Name of Law Firm(s) you appointed

Are or were you subject to a disciplinary hearing?

Yes

Disciplinary Hearing Date

Disaplinary Hearning Status

Have you been involved in CCMA Proceedings?

Tick the checkbox if you have.

First CCMA Date

CCMA Status (Describe)

Have you been involved in Labour Court Proceedings.

Tick the checkbox if you have.

First Labour Court Date

Labour Court Status (Describe)

Have you been involved in Magistrate's Court Proceedings.

Tick the box if you have.

First Magistrate Court Date

Magistrate Court Status (Describe)

Have you been involved in High Court Proceedings.

Tick the box if you have.

First High Court Date

High Court Status (Describe)

Have you been involved in Constitutional Court Proceedings.

Tick the box if you have.

First ConCourt Date

ConCourt Status (Describe)

Do you require Legal Support?

Tick the box if you require Legal Support.

Do you require Financial Support?

Tick the box if you require Financial Support.

Financial Details

Current Monthly Income (Own)

Current Monthly Income (Spouse, Child, Family Member)

Monthly Rental Income

Other Monthly Income (UIF, Pension, Grants)

Balance of savings and/or fixed deposit

Balance of transactional bank accounts

Value of Investment Account

Value of Pension fund and/or Annuities

Please upload you Credit Check report

Download your free credit check report from https://up.experian.co.za

Please upload your latest 3 bank statement

Bank Statement - Month 2

Bank Statement - Month 3

Please provide motivation for financial assistance request

Do you require Psychological Support?

Tick the box if you require Psychological Support.

Medical and Psychological Details

Could you provide a brief medical history?

Could you provide a short psychological and psychiatric history?

Could you provide details regaring your mental health concerns?

Do you have a medical aid membership?

Do you consent to psychological services provided by the service provider

Please tick the box if you agree.

Do you require Security Support?

Tick the box if you require Security Support.

Security Details

Do you fear for your physical safety?

Tick the box if you fear for your physical safety.

Do you feel under threat?

Tick the box if you fear for your physical safety.

Please elaborate on the threat

Is there a threat to safety and security of your family or loved ones?

Did your loved ones received direct or indirect threats?

Tick the box if the answer is yes.

Have these threats been reported to the South African Police Service?

Tick the box if the threats have been referred to the Police.

Is the security concerns at your workplace/residence?

Have you experienced signs of retaliation or intimidation related to the case?

Tick the box if you have.

Have you been approached for your information by anyone suspcious?

Tick the box if you have.

What are your current living arrangements?

Do you have a dedicated security provider at home?

Tick the box if you do.

Do you have intrusion alarms with an armed response?

Tick the box if you do.

Do you have physical barriers (gates and burglar proofing)?

Tick the box if you do.

Do you reside in a fenced property?

Tick the box if you do.

Elaborate on any residential security concerns you may have.

Tick the box if you do.

Do you have any social media accounts?

Tick the box if you do.

Do family or friends post or tag you on social media?

Tick the box if they do.

Do you use any online (cloud) storage services?

Tick the box if you do.

Please elaborate on the cloud services you use.

Do you have any personal security measures in place?

Tick the box if you do.

Do you use any credible anti-virus and malware software?

Tick the box if you do.

Do you regularly update these services?

Tick the box if you do.

Do you have any concerns of electronic breaches?

Tick the box if you do.

Please elaborate on these breaches.

Has there been any unauthorised access to your devices?

Tick the box if there have been.

Please eleborate on unauthorised access

Has any other person had access to your devices?

Tick the box if someone has.

Please elaborate on the access issues

Do you use different passwords accross different platforms?

Tick the box if you do.

Do you have any other Security Concerns?

Tick the box if you do.

Please provide additional details of your other security concerns.

Does your employer provide security at your current workplace?

Tick Yes if they do.

Could you provide details on security provided by your employer.

Do you often work late or arrive early hours at workplace?

Tick the box if you do.

Please elaborate on how often and under what circumstances.

Do you have any security concerns at your place of work?

Tick the box if you do.

Please provide details of your concerns.

Do you use shared transport?

Please tick the box if you do.

Please confirm that the information provided above is true and correct *

Please tick the box if you agree.

Confirm that you have read and accept the terms of service *

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Sign Up as a Whistleblower

Whistleblower Incident Information

Financial Details

Medical and Psychological Details

Security Details

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