Bullying and Harassment Questionnaire

Section 111(1) of the Workers' Compensation Act charges WorkSafeBC to be concerned with occupational health and safety generally. In carrying out its mandate WorkSafeBC may undertake inspections, investigations and inquiries on matters of occupational health and safety and occupational environments (s. 111(2)(b)). WorkSafeBC may investigate complaints concerning health and safety at a workplace and, for the purpose of conducting an inspection, may question people with respect to matters that may be relevant to the inspection (s. 179(3)(h)).

The purpose of this questionnaire is for WorkSafeBC to gather the information we need to undertake an inquiry into an occupational health and safety complaint of workplace bullying and harassment.

WorkSafeBC will generally only inquire into allegations of workplace bullying and harassment when there are reasonable grounds to believe that an employer has failed to address the issue. Please report all incidents or complaints of workplace bullying and harassment to your employer before submitting this complaint form. Please also read the information in the Prevention Guideline G-D3-115(1)-3 Bullying and harassment.

In following up on any complaint, WorkSafeBC's role is not to resolve or mediate any specific disputes or conflicts. Our role is to ensure employers have adequate policies, procedures and training to prevent and address workplace bullying and harassment. When we receive a complaint of workplace bullying and harassment, WorkSafeBC's role is to ensure the employer has conducted an investigation that is fair, impartial and is focused on finding facts and evidence.

If you need help with this form, please call 604 276-3100, or toll free at 1-888-621-7233.

Date bullying and harassment questionnaire submitted to WorkSafeBC:  2019/10/15



Required field

Worker information

Your name

 

Your address

Your contact information (enter at least one phone number)


Employer information

Name of the person you report to:

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Years
Months
 
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Alleged bully(ies) and harasser(s) information

Alleged bully or harasser #1

Alleged bully or harasser #2

Alleged bully or harasser #3

Alleged bully or harasser #4

Witness(es) information

Witness #1

Witness #2

Witness #3

Witness #4

Complaint details

 
 
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Other complaints or investigations


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Additional comments

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Acknowledgement and permission

Please note that in conducting an inquiry into your occupational health and safety complaint WorkSafeBC may need to notify and follow-up with your employer. Failure to accept this acknowledgement and permission will limit WorkSafeBC's ability to address your specific complaint and to take any further action to ensure full compliance with the Workers’ Compensation Act and associated policies.

Name of complainant: 
Date: 2019/10/15
Personal information on this form is collected for the purposes of investigating a complaint of workplace bullying and harassment by WorkSafeBC in accordance with the Workers' Compensation Act and the Freedom of Information and Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604 279-8171.

If you need help with this form or if you have questions about workplace bullying and harassment policies, please call 604 276-3100, or toll free at 1-888-621-7233.