Ombudsman Notification Form

CM REF:

Date of Disclosure

dd/mm/yyyy

Public Body Name:

DEPARTMENT OF JUSTICE

Details of Officer (completing assessment):

Name:

Tel:

Email:

Date of section 33 determination

(made within 45 days of date of disclosure)

dd/mm/yyyy

Date of Notification

dd/mm/yyyy

Select

Act Ref

Description

Notification/Investigation Requirements

☐

section 34

Determination that disclosure is a public interest disclosure

Notification to be made within 14 days of decision

☐

section 35

Determination that disclosure is not a public interest disclosure

Notification to made within 14 days of decision

☐

section 65

Decision not to investigate public interest disclosure (under s 64)

Notification to be made within 14 days of decision

☐

section 76

Findings of investigation and steps taken under s 75

Investigation to be completed within 6 months unless Ombudsman extension granted.

Select

Description

☐

Copy of original disclosure or record of oral disclosure

☐

Disclosure assessment

☐

Risk assessment/s

☐

Investigation Report including:

• the   transcript or other record of any oral evidence taken, including audio and   video recordings; and
• all   documents, statements or other exhibits received by the Investigator and   accepted as evidence during the course of the investigation

☐

Any other material used to make the determination (please list)

o

o

o