"Workplace Violence and Harassment Complaint Form - the Protestant Separate School Board of the Town of Penetanguishene" - Canada

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THE PROTESTANT SEPARATE SCHOOL BOARD
OF THE TOWN OF PENETANGUISHENE
VILLAGE SQUARE MALL
2 POYNTZ STREET, BOX 107
PENETANGUISHENE, ONTARIO L9M 1M2
TELEPHONE (705) 549-6422 FAX (705) 549-2768
APPENDIX B
Workplace Violence and Harassment Complaint Form
COMPLAINANT INFORMATION
Violence and/or harassment was directed towards
___________________________________________________________________________________________________________
Name of Complainant:
Title/Position:
Worksite:
Additional Information:
Supervisor/Manager’s Name:
Supervisor Title/Position:
Supervisor Work Phone:
RESPONDENT INFORMATION
Violence and/or harassment was directed by
___________________________________________________________________________________________________________
Name of Respondent:
Title/Position:
Worksite:
INITIATOR INFORMATION
Complete this section only if the employee who initially identified the offensive behaviour is different from the complainant
___________________________________________________________________________________________________________
Name of Person Making the Report (if different from above):
Title/Position:
Worksite:
PRE-STEP
Was the respondent advised that the behaviour was unwelcome?
Yes
No
Date Complainant advised Respondent that the behaviour was unwelcome:
Policy C-10a APPENDIX B
THE PROTESTANT SEPARATE SCHOOL BOARD
OF THE TOWN OF PENETANGUISHENE
VILLAGE SQUARE MALL
2 POYNTZ STREET, BOX 107
PENETANGUISHENE, ONTARIO L9M 1M2
TELEPHONE (705) 549-6422 FAX (705) 549-2768
APPENDIX B
Workplace Violence and Harassment Complaint Form
COMPLAINANT INFORMATION
Violence and/or harassment was directed towards
___________________________________________________________________________________________________________
Name of Complainant:
Title/Position:
Worksite:
Additional Information:
Supervisor/Manager’s Name:
Supervisor Title/Position:
Supervisor Work Phone:
RESPONDENT INFORMATION
Violence and/or harassment was directed by
___________________________________________________________________________________________________________
Name of Respondent:
Title/Position:
Worksite:
INITIATOR INFORMATION
Complete this section only if the employee who initially identified the offensive behaviour is different from the complainant
___________________________________________________________________________________________________________
Name of Person Making the Report (if different from above):
Title/Position:
Worksite:
PRE-STEP
Was the respondent advised that the behaviour was unwelcome?
Yes
No
Date Complainant advised Respondent that the behaviour was unwelcome:
Policy C-10a APPENDIX B
INFORMAL RESOLUTION
Was the informal resolution process attempted:
Yes
No
Name of Supervisory/Managerial Personnel involved in the informal resolution:
Date Complainant reported unwelcome behaviour to the above noted person:
Describe the informal Resolution attempt taken and why it failed:
FORMAL COMPLAINT
Describe the alleged discrimination/harassment. Set out all facts, in chronological order, on which the complaint is based. Include
dates, times, locations, the identity of witnesses, and a description of the steps already taken to resolve the matter. Attach additional
pages if necessary.
RESOLUTION REQUESTED
Explain the resolution you believe would resolve this matter.
I acknowledge having read the Workplace Violence and Harassment Prevention Policy. I hereby certify that to the best of my
knowledge the above-mentioned information is true, accurate and complete. I understand that making false or frivolous allegations is
in violation of this policy and is subject to disciplinary sanctions.
Initiator/Complainant Signature:
Date:
INSTRUCTION FOR SUBMITTING THIS FORM:
PLACE THIS FORM IN A SEALED ENVELOPE MARKED
“PRIVATE AND CONFIDENTIAL”
AND FORWARD TO THE SUPERVISORY OFFICER
INFORMATION COLLECTION AUTHORIZATION:
The personal information contained on this form has been collected under the authority of the Occupational Health and Safety Act, the
Municipal Freedom of Information and Protection of Privacy Act, and the Personal Health Information Privacy Act, and will be used to
investigate incidents of workplace violence and harassment. This form will be used by the Supervisor of the department, Legal Counsel
and the Ministry of Labour staff. The form will be handled with the strictest confidence, stored in a locked and secure file cabinet in the
Protestant Separate School Board office and retained for a three year period. Questions pertaining to the collection of this information
should be directed to the Supervisory Officer of the Board.
COPIES:
1.
Supervisory Officer
2.
Employee’s Supervisor
3.
Complainant
4.
Respondent
5.
Initiator
Policy C-10a APPENDIX B
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