Office Bullying and Harassment Policy Volume Nov 2013 | Page 6

Venus Furniture Ltd Workplace bullying and harassment complaint form Name and contact information of complainant Name of alleged bully or bullies Personal statement Please describe in as much detail as possible the bullying and harassment incident(s), including: • the names of the parties involved • any witnesses to the incident(s) • the location, date, and time of the incident(s) • details about the incident(s) (behaviour and/or words used) • any additional details that would help with an investigation Attach any supporting documents, such as emails, handwritten notes, or photographs. Physical evidence, such as vandalized personal belongings, can also be submitted. Signature Date