Whistleblower Reporting Form 

This form is to be used by directors, officers, employees, contractors, or volunteers of  Journey House Foundation, Inc. to report suspected misconduct, violations of law, or  breaches of policy in good faith. Reports may be submitted to the Executive Director or,  if the concern involves the Executive Director, to the Chair of the Board of Directors.

Name of Reporter (optional): ______________________________ Date of Report: ______________________________ 

Role/Position: employee, volunteer, board member, other:_____________________ 

Description of Concern (include details, dates, individuals involved, and any  supporting information): 

________________________________________________________ ________________________________________________________ ________________________________________________________ 

Have you previously reported this concern to anyone? If yes, please provide details: ________________________________________________________ 

________________________________________________________ ________________________________________________________ 

Requested Outcome/Resolution: 

________________________________________________________ ________________________________________________________ ________________________________________________________ 

Signature (if not anonymous): 

________________________________________________________

________________________________________________________ ________________________________________________________ 

Confidentiality will be maintained to the fullest extent possible, consistent with the need  to conduct an adequate investigation. Retaliation against anyone who files a report in  good faith is strictly prohibited.