Full Name

Job that you perform

Facility where you work

Cel Phone

Email Address

¿The DENOUNCED - is head of the Victim? *
YesNo

¿The DEFENDANT - works directly with the Victim? *
YesNo

¿You have reported this situation to your immediate superior? *
YesNo

RELATE THE FACTS YOU REPORT

Indicate the date and place of the event, name of those involved, explaining what happened *

If you have evidence that you can accompany for the investigation, select: *
NonewitnessesVideosEmailsPictures

If you answered "Witnesses" or "Other Supporting Documents", please check them *

If you have evidence please attach it.