WorkSafeBC Online - Bullying and Harassment Questionnaire

Bullying and Harassment Questionnaire

Section 17(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. 17(2)(b)). WorkSafeBC may investigate complaints concerning health and safety at a workplace (s. 75(1)(c)) and, for the purpose of conducting an inspection, may question people with respect to matters that may be relevant to the inspection (s. 75(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-P2-21(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: 2024/04/26

Required field

Worker information

Your name

First name:

Initial:

Last name:

Date of birth:

Invalid

Your address

Address Line 1:

Address Line 2:

City:

Province/State:

Postal/Zip code:

Country:

Your contact information (enter at least one phone number)

Home:

Work:

Cell:

Email:

Employer information

Employer name:

Address Line 1:

Address Line 2:

City:

Province:

Postal/Zip code:

Telephone:

Name of the person you report to:

Salutation

First name

Initial

Last name

The job title of the person you report to:

What industry do you work in?

Describe your occupation, position or responsibilities at work:

0 of 1000 characters allowed.

How long have you worked for this employer?

Years

Months

Do you still work for this employer? YesNo

If not, when was your last day of work?

Invalid

If you no longer work for this employer, why did you stop working for them?

0 of 1000 characters allowed.

Does your employer have a Bullying and Harassment policy statement? YesNoI don't know

Does your employer have a Bullying and Harassment reporting and investigation procedures? YesNoI don't know

Has your employer provided Bullying and Harassment training? YesNoI don't know

Have you reported the bullying and harassment to your employer or supervisor? YesNo

If yes, who did you report it to and when:

0 of 500 characters allowed.

If yes, what is the prohibited action file number?

Have you filed a report with the police about the bullying and harassment? YesNo

If yes, what is the police file number?

What, if any, action or response has there been?

0 of 1000 characters allowed.

Have you spoken with or filed a complaint with the BC Human Rights Tribunal? YesNo

If yes, what, if any, response has there been?

0 of 1000 characters allowed.

Additional comments

Is there anything else you think WorkSafeBC should know about this complaint?

0 of 1000 characters allowed.

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.

I declare all the information provided in this Questionnaire is true to the best of my knowledge.

I acknowledge that details of my complaint will need to be discussed with my employer and other persons for the purpose of inquiring into this complaint. I hereby give WorkSafeBC permission to undertake this inquiry. I acknowledge that confidentiality cannot be assured.

YesNo

I consent to the use of the information provided in this questionnaire for purposes of related claims for compensation for a workplace injury or occupational disease or for any related prohibited action complaints made under the Workers’ Compensation Act"

Name of complainant:

Date: 2024/04/26

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.

Worker information

Your name

Your address

Your contact information (enter at least one phone number)

Employer information

Name of the person you report to:

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

Other complaints or investigations

Additional comments

Acknowledgement and permission

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