Complaint Form Bullying In The Workplace - Nsw Trade & Investment Mine Safety
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3Complaint form – bullying in the workplace
Bullying in the workplace is defined as ‘repeated, unreasonable behaviour directed towards a worker or group of workers that
creates a risk to health and safety’. A single incident or reasonable workplace action is not bullying.
Complete this form and send it to NSW Trade & Investment Mine Safety if what happened to you meets the definition of bullying
and:
•
you have reported it to your workplace and there has been no action, or you believe the action taken was
inappropriate, or
•
you are unable to report it in your workplace because there is no procedure or you are concerned for your health and
safety.
NSW Trade & Investment Mine Safety will assess the information you provide before deciding on the most appropriate course of
action, which may include:
•
consulting with the parties involved;
•
advising and guiding the workplace on how to prevent and respond to bullying;
•
referring the matter to another agency if it falls outside Mine Safety’s jurisdiction;
•
gathering more information in relation to possible breaches of work health and safety legislation;
•
taking no further action.
Personal detail (of the person raising the issue with NSW Trade & Investment Mine Safety)
First name
Last name
Salutation
Mr
Mrs
Ms
Miss
Dr
Other:
Home address
Postal address
Email address
Home telephone
Mobile
Are you the person who was allegedly bullied?
Yes
No
If NO, please supply the name and contact details of the person who was allegedly bullied
First name
Last name
Home telephone
Mobile
Do you have the consent of this person to raise this issue with NSW Mine
Yes
No
Safety?
Consent
Do you consent to NSW Mine Safety raising this issue of alleged bullying
Yes
No
with the relevant workplace parties?
(If NO, NSW Mine Safety cannot take any action. Do not continue to
complete this form)
Do you consent to NSW Mine Safety making the workplace parties aware
Yes
No
that the issue has been raised by you?
(If NO, please be aware that the workplace parties may assume that the
issue has been raised by the person being bullied)
Workplace details (where the alleged bullying occurred)
Business name
Address
What industry is the business
in?
Where did the alleged bullying
occur?
INT14/52974 June 2014
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