Employee Concern Form

What is the nature of your concern	Nuclear Safety Related Health Equal Employment Opportunities Workplace Violence HIRD related to a Nuclear Safety Related Concern Quality Safety Multiple Concerns Fraud/Waste/Abuse Employee Relations Security Environmental Management Misconduct Other Invalid Input
Describe Concern	Invalid Input
What do you believe may be the consequence(s) of your concern if it remains unresolved	Nuclear Safety Compromised Injury to myself or another Loss of Life Loss of Job Breech of Security Environmental Damage Other Invalid Input
Have you reported or spoken of your concern to another individual	Invalid Input	(if so provide names(s)
Have you reported your concern to an organization outside of ZNI	Invalid Input	(if so provide names(s))
Why did you choose this avenue to report your concerns	Lack of Trust in Management Dissatisfaction with Corrective Action Fear of Retaliation Lack of Response Other Invalid Input
	Contact Information
Degree of Confidentiality Requested	Invalid Input
Name or Code Word	Invalid Input
Date	Invalid Input
Phone Number	Invalid Input
E-mail address	Invalid Input
Contact Address	Invalid Input
Spam Filter	Refresh Invalid Input
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