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 [Name of Contact Person] or [Email Address]. All information will be kept confidential to the extent possible.

1. Complainant Details

Name: [First Name] [Last Name]

Job Title: [Job Title]

Work Location / Site: [Address or Site Name]

Phone Number: [Phone Number]

Email Address: [Email Address]

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

2. Person Against Whom the Complaint is Made

Name: [First Name] [Last Name]

Job Title: [Job Title]

Relationship to Complainant: [e.g. Supervisor, Co-worker, Client, Subcontractor]

3. Details of the Complaint

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

Description of the Incident(s): [Please describe exactly what happened. Be specific about the words used, actions taken and the context.]

[Space for response]

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

Dates and Times of Incidents: [Date 1]: [Time] - [Brief detail] [Date 2]: [Time] - [Brief detail] [Date 3]: [Time] - [Brief detail]

Location of Incidents: [e.g. Construction site, Lunchroom, Office, Via Phone/Text]

4. Witnesses

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

If yes, please provide their names and contact details:

1. [Name] - [Role/Relationship]
2. [Name] - [Role/Relationship]

5. Evidence

Is there any physical evidence available? [ ] Emails [ ] Text messages [ ] Photos [ ] Video [ ] Social Media posts [ ] Medical certificates [ ] Notes/ Diary [ ] None

Please attach copies of this evidence to this form.

6. Impact

How has this behaviour affected you? [Describe any physical or mental impacts, impact on work performance, or desire to leave the job.]

[Space for response]

7. Resolution

What outcome would you like to see from this complaint? [e.g. Formal investigation, Mediation, Informal discussion, No action required just want it on record]

[Space for response]

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:

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Date: [DD/MM/YYYY]

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For Office Use Only:

Date Received: [DD/MM/YYYY]

Received By: [Name]

Action Taken: [Space for notes]