Name of complainant:
(Required)
First
Last
Phone Number
(Required)
Email
Subject of Complaint:
(Required)
Incident Date
Incident Time
Hours
:
Minutes
AM
PM
AM/PM
Where did it happen?
Who was present?
(Required)
Who witnessed the incident?
What happened? What was said and who said what?
(Required)
Would you consider this to be bullying or harassment? (i.e. why was this unreasonable? Was it a repeated incident, and how? How did it endanger your health, safety or wellbeing?)
How did this incident make you feel? How has this incident affected you?
Have you taken any actions? If so, what?
As a result of this complaint, what do you want to happen?
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