Incident Report Form Page 3

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Section 4
Repeated Behaviour
The behaviour does not always have to take the same form. Rather, it is
persistent and established. The bullying behaviour may consist of a variety of
diverse forms. How often does the unreasonable behaviour identified in
section 3 occur?
Once per day
More than once per day – how many times?
Once per week
More than once per week – how many times?
Other, please provide further information
Section 5
Details of the Incident
Briefly describe what happened.
When did the incident occur?
Was the behaviour directed at other employees as well as yourself?
Yes
No
Who witnessed the incident
Nobody
Name of witness 1
Name of witness 2
Name of witness 3
Do you have any of the following which may be used to support your
allegation
E-mail
Letters
Diary notes and entries
Personal journals
Section 6
How the Incident Was Reported
Have you experienced bullying in this workplace prior to this incident?
Yes
No
Have you reported prior incidents of bullying?
Yes – Please provide brief details of when and what the
outcome was
No – Please provide details of why you did not report the
incident.

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