Improper Acts Reporting Procedure


This Procedure describes the responsibilities and processes associated with receipt of a Report under the Improper Acts Reporting Policy. Defined terms are found in the Policy.


Reporting Officer 

1. It is the responsibility of the Reporting Officer to refer reports to the intake process of the most applicable policy or procedure of the university for assessment and/or investigation. 

2. If a matter is referred for investigation, the person charged with overseeing that investigation will become a Responsible Officer under this policy and will fulfill the obligations of that role, in addition to any other obligations that they may have under other university policies or procedures. 

3. If a report is not accepted for investigation under the provisions of another university policy or procedure, the Reporting Officer will be advised of the reasons why and they shall then be given to the Reporter (if not anonymous).

4. If there is no applicable policy or procedure, the Reporting Officer may designate a Responsible Officer to undertake an investigation where the facts as alleged, if true, would constitute an Improper Act and it would be possible to undertake a fair, impartial, competent investigation; if the Reporter is anonymous or does not wish to share their identity with anyone other than the Reporting Officer, this may only be possible in circumstances where disclosure of the Reporter’s identity would not be necessary to undertake a fair and competent investigation. .

5. Reports and outcomes from investigations are generally confidential. But where it is permissible and appropriate to share information with the Reporter (if not anonymous) regarding the conclusion of an investigation, the Reporting Officer may do so. 

6. The Reporting Officer will prepare a report for each meeting of the Audit and Risk Committee of the Board which summarizes the reports received under this policy since the last such report, and an annual summary of all reports received each year for the Board of Trustees. Annual reports will be posted on the webpage of the Reporting Officer together with those from not less than the most recent four years.

7. The Reporting Officer will maintain effective and confidential channels of communication to support the policy and this procedure and, together with senior administrators, is responsible for regular outreach and communication with the Members of the University Community to bring awareness of this policy to their attention.

8. The Reporting Officer will bring to the immediate attention of the Chair of the Audit and Risk Committee any reports received that disclose significant risk to the university (reputationally, financially, or otherwise) or relate to the duties or responsibilities of Trustees as required by law. Only that information necessary to assess and oversee the response to risks to the organization or ensure fulfillment of duties and responsibilities of Trustees as required by law will be shared with the Chair of the Audit and Risk Committee and otherwise, confidentiality will be maintained to the extent possible.

Responsible Officer

9. Upon receiving a report, the Responsible Officer will appoint or retain an Investigator who shall fully, fairly, impartially, and competently investigate the matter. 

10. Where an investigation will take more than one month to complete, the Responsible Officer will provide regular updates to the Reporting Officer on its status.

11. If the Responsible Officer becomes aware of an alleged Reprisal, where the facts upon which the allegation of Reprisal, if true, would constitute a violation of this or any other University policy or procedure they shall report this to the Reporting Officer and will investigate it.

12. The Responsible Officer will provide a summary of the findings and actions taken in response to the report and any alleged Reprisals to the Reporting Officer.


13.    To the extent reasonably possible and within the limitations of the law and of this and other applicable policies and procedures, and of the need to conduct a competent, fair, impartial investigation, investigators shall protect the identity of the Reporter.  Where it appears that this protection cannot be maintained, the Investigator will immediately notify the Responsible Officer and the Reporting Officer. The Responsible Officer will consult with the Reporter through the Reporting Officer regarding what options are available for proceeding. Following this consultation, the Responsible Officer will provide direction to the Investigator.

14.    Where the Investigator becomes aware of an alleged Reprisal or other Improper Act or has reasonable cause to believe there is a risk to the health or safety of any Member of the University Community, the Investigator will immediately report this to the Responsible Officer. The Responsible Officer will determine whether the mandate for the investigation should be altered to include the new matter or whether a separate investigation of it should occur.

15.    Any potential or apparent breaches of confidentiality shall be reported to the Responsible Officer who will in turn inform the Reporter (if not anonymous) through the Reporting Officer.

Reporters and Witnesses

16.    Any person who believes that they have experienced a Reprisal because of making a report of an alleged Improper Act or participating in a process pursuant to this or any related policy or procedure of the university, should document the details and immediately inform the Responsible Officer and the Reporting Officer.  Where the facts upon which the allegation of Reprisal, if true, would constitute a violation of this or any other University policy or procedure, the Responsible Officer shall ensure that the allegation of Reprisal is investigated and, if justified, that the appropriate corrective steps are taken.

17.    Details and results of investigations are confidential within the limitations of the law, collective agreements, and University policies. All Reporters and witnesses involved in a Report or an investigation shall not disclose or discuss the details or results of an investigation with anyone other than personnel associated with the University who have a need to know such details or results in order to perform their duties. These provisions do not restrict seeking advice or support from the Office of the Ombudsperson, the Human Rights and Equity Office, personnel performing roles pursuant to collective agreements, legal counsel or regulated health professionals provided that the same rules of confidentiality will apply to persons performing these roles.

Contact Officer:                  University Secretary
Date Approved:                   May 13, 2022
Approval Authority:             Senior Leadership Team
Date of Commencement:   TBC
Amendment Dates:             n/a
Date for Next Review:        TBC

Related Policies, Procedures, and Guidelines: