Statement of Purpose

The MacLean-Fogg Ethics and Compliance Report Form is intended for use by HR personnel. This Form is used to capture any concern or question reported to you that falls into one or multiple categories listed here:

A violation / potential violation of the Law / Regulations
A violation / potential violation of A MacLean-Fogg policy / procedure
A violation / potential violation of A Division policy / procedure
The risk of a lawsuit
A concern about unethical behavior / unethical decisions

Use the EthicsPoint Decision Tree to assign the most accurate Issue Selection. This can be updated later if necessary.

The details of your submission can only be viewed by authorized users. You may be contacted for additional information after further review of your submission.

Items marked with a diamond ♦ are required fields.

Your Information (You, the person completing the form)

	Save “Your Name & Contact Information” for future use. (By checking this box you agree to allow NAVEX Global to store your information in a “Cookie” on this computer.)

Your Name & Contact Information	Prefix (Select One) ♦ First Name M.I. ♦ Last Name Job Title Employee ID (Clock #) Phone Number (Preferred) Include the area code, extension, and/or dialing codes if applicable. Phone Number (Alternative) Include the area code, extension, and/or dialing codes if applicable. ♦ Email (Format: username@domain.com)

Reported By (The person who brought this incident to the company's attention)

Reporter	♦ Was this issue/event raised by another individual? Yes No (Select One)

Reporter Name & Contact Information	♦ Relationship to the Company (Select One) ♦ “Other” Relationship Prefix (Select One) ♦ First Name M.I. ♦ Last Name Job Title Employee ID (Clock #) ♦ Phone Number (Preferred) Include the area code, extension, and/or dialing codes if applicable. Phone Number (Alternative) Include the area code, extension, and/or dialing codes if applicable. ♦ Email (Format: username@domain.com)

Reporter Name &
Contact Information

♦

Relationship to the Company

(Select One)

♦

“Other” Relationship

Prefix

(Select One)

♦

First Name

M.I.

♦

Last Name

Job Title

Employee ID (Clock #)

♦

Phone Number (Preferred)

Include the area code, extension,
and/or dialing codes if applicable.

Phone Number (Alternative)

Include the area code, extension,
and/or dialing codes if applicable.

♦

(Format: username@domain.com)

Location

Location

Issue Selection

Incident Details

Date	♦ Approximate date of issue/incident. (Format: mm/dd/yyyy)

Details	♦ Provide all details regarding the alleged violation, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation.

Previously Reported	♦ Has this issue/incident been previously reported? Yes No Do Not Know (Select One) ♦ Approximate date of when was this previously reported? (Format: mm/dd/yyyy) ♦ To whom was this previously reported?

Participants (Including but not limited to “Implicated Persons”, “Accomplices”, and/or “Witnesses”)

Participants	♦ Were any “Participants” involved in this incident? Yes No (Select One)