This intake form enables Emergent HR team members to enter case information to open
a new case in the dedicated HR tier within Emergent’s EthicsPoint Case Investigations
System. HR case information should be entered as early as practicable after the initiation of an
HR investigation that meets the criteria defined in coordination with E&C and HR leadership. Submitted
data will be handled and maintained consistent with Emergent’s Corporate Internal Investigations policy.
If you have questions about whether a case meets the criteria, contact an HR Senior Director for guidance.

Once an investigation has been completed, update the case record with closure information by logging into EthicsPoint with the login credentials provided by E&C. If you have questions regarding this form or accessing EthicsPoint please contact Matt Haaga (haagam@ebsi.com).

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 ♦ 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 ♦ 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)

Incident Details

Date	♦ Approximate Date of 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?

Location of Incident

Location

File Upload

File Upload	Here you can upload files and documents for the company to review that are related to this report. Please note: HR team members are not required to upload case files when opening a case using this form. If you are uncertain whether certain documents or information should be entered into Ethicspoint, please obtain guidance from the Sr. Director for HR Compliance before submitting. Select a file File Description Files Uploaded: Space Remaining: Max File Size: Errors:

Here you can upload files and documents for the company to review that are related to this report.

Please note: HR team members are not required to upload case files when opening a case using this form. If you are uncertain whether certain documents or information should be entered into Ethicspoint, please obtain guidance from the Sr. Director for HR Compliance before submitting.

Select a file

File Description

Files Uploaded:

Space Remaining:

Max File Size:

Errors:

Issue Selection

	Add Issue Add Issue

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

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

Investigator Information

Investigator Information	I am a Subject Matter Expert in the matter to be investigated Yes No (Select One)

	I have been trained to conduct investigations Yes No (Select One)

	I am objective and independent, meaning: a. I am not serving in the subject’s chain of command (matrixed or direct); b. I am not involved in any way with and do not have any direct knowledge of the matter being investigated; c. I have no reason to believe that conducting the investigation presents an actual or apparent conflict of interest; and d. The site leader is not the subject of the investigation. Yes No (Select One)

I am objective and independent, meaning:
a. I am not serving in the subject’s chain of command (matrixed or direct);
b. I am not involved in any way with and do not have any direct knowledge of the matter being investigated;
c. I have no reason to believe that conducting the investigation presents an actual or apparent conflict of interest; and
d. The site leader is not the subject of the investigation.

Yes No

(Select One)

Human Resources Case Submittal Form