Bullying and Harassment Complaint Form

Instructions Please complete this form if you wish to make a formal complaint about bullying or harassment. You may complete this form yourself or with the assistance of a support person. Return this form to Sarah Jenkins, Site Manager, or email sarah@buildright.com.au. All information will be kept confidential to the extent possible.

1. Complainant Details

Name: Mike Ross

Job Title: Second Year Electrician Apprentice

Work Location / Site: 123 Harbour View Development, Site B

Phone Number: 0412 345 678

Email Address: mike.ross@email.com

Is an interpreter or support person required? [X] No

2. Person Against Whom the Complaint is Made

Name: David Smith

Job Title: Leading Hand

Relationship to Complainant: Direct Supervisor

3. Details of the Complaint

Type of Behaviour (Please tick all that apply): [X] Verbal Abuse [ ] Humiliation [ ] Exclusion/Isolation [X] Unreasonable work demands [ ] Sexual Harassment [ ] Physical Intimidation [ ] Cyber Bullying [X] Other (please specify): Swearing and aggressive shouting.

Description of the Incident(s): On three occasions this week, David has yelled at me in front of the other trades. On Monday, he called me a "muppet" and said I was "useless" because I took 5 minutes longer than expected to wire a switchboard. Yesterday, he threw my tool belt on the ground because I had left it near the walkway (it was not blocking the path). He shouted that I was a "lazy idiot" and that if I didn't "pull my head in" he would make sure I never got signed off.

Frequency of Behaviour: [ ] One off incident [ ] Occasional [X] Frequent / Daily [ ] Ongoing for [Time Period]: 3 weeks

Dates and Times of Incidents: [Date 1]: 12/09/2023 - 2:00pm - Swearing and name calling regarding switchboard speed. [Date 2]: 13/09/2023 - 7:30am - Throwing tool belt and shouting regarding site cleanliness. [Date 3]: 15/09/2023 - 10:00am - Aggressive micromanagement, standing over me while I worked.

Location of Incidents: Ground floor electrical room and main corridor.

4. Witnesses

Were there any witnesses to the incident(s)? [X] Yes [ ] No

If yes, please provide their names and contact details:

1. Tom Jones - Plumber (saw the tool belt incident)
2. Sarah Lee - Labourer (was present during the shouting)

5. Evidence

Is there any physical evidence available? [ ] Emails [ ] Text messages [ ] Photos [ ] Video [ ] Social Media posts [ ] Medical certificates [X] Notes/ Diary: I have kept a diary of the times and dates. [ ] None

Please attach copies of this evidence to this form. Attached: Diary entries.

6. Impact

How has this behaviour affected you? I feel anxious about coming to work. I am making mistakes because I am stressed about David watching me. I have trouble sleeping. I am considering quitting my apprenticeship.

7. Resolution

What outcome would you like to see from this complaint? I want the yelling and name calling to stop. I want to be moved to a different crew or have David moved. I do not want to work directly under him anymore.

8. Declaration

I declare that the information provided in this form is true and correct to the best of my knowledge. I understand that making a false complaint knowingly may have disciplinary consequences.

Signature: M. Ross

Date: 16/09/2023

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For Office Use Only:

Date Received: 16/09/2023

Received By: Sarah Jenkins

Action Taken: Initial interview with complainant scheduled 17/09. Drafting invitation to interview for respondent. Safety risk assessment required.