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Ethics Complaint Form

1. Identify the location (city, country, office) where the issue occurred

2. Identify your relationship to PYXERA Global

EmployeeConsultantVendor/Service ProviderGranteeOther/Anonymous (would prefer not to say)

3. Type of Ethics issue/violation

Accounting, Auditing, Billing and Internal Financial ControlsConflict of InterestDiscrimination or HarassmentIllegal or Fraudulent ConductPolicy ViolationRetaliationSubstance AbuseTheftOther

Other description

4. Urgency

HighMediumLow

5. Persons engaged in reported behavior (Full name(s) and Title(s)

6. Do you suspect or know that supervisors or management are involved

YesNoDo not wish to answer

7. If a supervisor or management are involved, please provide full names and titles?

8. Is management aware of the problem?

YesNoDon't know

9. When did the incident or violation occur and/or how long has this been a problem (explain if on-going or multiple events)?

10. How did you become aware of the incident or violation? Happened to me/I observed it/I heard it/I was told by a coworker/I was told by someone outside of the company/I found a document or file/Other (explain)

11. Has anyone attempted to conceal the incident or violation?

YesNoI don't know

12. If someone attempted to conceal the incident or violation, please identify the person(s) and the measures taken to conceal (e.g. falsifying documents, stalling investigation, etc.)

13. Upload any documents or files that you have that may support the statements made in this report

Non-anonymous question

14. Description of Issue (please provide all the details)

Enter your Name and contact information or elect to submit as anonymous

Your Name

Phone Number (include country code)

Email

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