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Work Health and Safety Act 2011 (WHS Act) – Work Health and Safety Regulation 2011 (WHS Regulation)

WORKPLACE BULLYING FORMHow to fill in this formPlease type directly into the form. When complete, save a copy before emailing or printing.If completing by hand, please print clearly and mark box(es) with a tick where required.

For assistance call 13 10 50

FeesThere is no fee associated with this form.

Lodgement instructionsPost: Customer Experience, SafeWork NSW, Locked Bag 2906, Lisarow, NSW 2252.

Privacy compliance statementPersonal information collected in this form is collected by SafeWork NSW in accordance with the Privacy and Personal Information Protection Act 1998 (PPIP Act). SafeWork NSW respects your privacy and is committed to protecting your personal information.We collect your personal information to provide our services to you, to improve the quality of our services and to provide you with information about other services we offer. You are required to provide this information in order for us to process your request form. Failure to provide the information may result in us not being able to process your request form. You have the right to access and correct your personal information. You can do this at any time by contacting SafeWork’s customer service centre on 13 10 50 or in writing to 92-100 Donnison Street, Gosford, NSW 2250. Further information on our privacy policy is available at safework.nsw.gov.au

Workplace bullying is repeated and unreasonable behaviour directed towards a worker or group of workers that creates a risk to health and safety.Please tick the box below to comply with the following conditions:1. I have checked that what is occurring is workplace bullying2. I accept SafeWork NSW’s service standards with regard to workplace bullying3. I consent to SafeWork NSW raising the issue of alleged workplace bullying with the relevant workplace parties.

I agree with the above conditions*

Are you the person who was allegedly bullied?* Yes No

If NO, you must attach that person’s written consent for you to raise this issue with SafeWork NSW. If you do not provide their written consent, SafeWork NSW will not action your request.

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SecTion 1. your DeTaiLS

You can remain anonymous if you wish. However, if you do, the action taken by SafeWork NSW is likely to be limited and you will not receive feedback on any action taken.

Do you consent to SafeWork NSW identifying you to the workplace parties as the person who has raised the issue?*

Yes No

Title Given name Family/Surname

Unit number/Street number/Property number (include Lot or DP number if applicable) Street name

Suburb State Postcode

Daytime contact number Email

Are you an apprentice or trainee?* Yes No

Are you under 25 years old?* Yes NoWhat is your relationship to the workplace where the alleged bullying occurred? (tick all that apply)*

Worker Ex-worker Health and safety representative

Member of the public Union Member Other

If Other, provide details

SecTion 2. WorkPLace DeTaiLS (WHERE THE ALLEGED BULLYING OCCURRED)Business name

Unit number/Street number/Property number (include Lot or DP number if applicable) Street name

Suburb State Postcode

Contact number Email

Main business activity (eg furniture manufacture, steel warehousing, fashion retail)*

Where in the workplace did the alleged bullying occur?*

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Listed below are some examples of behaviour that may be workplace bullying if they are repeated andunreasonable and if they create a risk to health and safety. Tick any of these that are relevant:*

unjustified criticism or complaints

deliberately excluding someone from workplace activities

withholding information that is vital for effective work performance

setting unreasonable timelines or constantly changing deadlines

denying access to information/supervision/consultation or resources to the detriment of the worker

spreading misinformation or malicious rumours

changing work arrangements such as rosters and leave to deliberately inconvenience a particular worker or workers

setting tasks that are unreasonably below or beyond a person’s skill level

abusive/insulting or offensive language or comments

other

If other, provide a brief description

Provide three specific examples that you think are significant in contributing to your allegation of workplace bullying.

eXamPLe 1Date that it happened* (DD/MM/YYYY)

Name and position of the person who allegedly behaved this way*

Relationship of this person to you. For example co-worker, person I supervise, supervisor, manager, owner*

Name/position of any witnesses*

What happened? What was said or done?*

eXamPLe 2Date that it happened* (DD/MM/YYYY)

Name and position of the person who allegedly behaved this way*

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Relationship of this person to you. For example co-worker, person I supervise, supervisor, manager, owner*

Name/position of any witnesses*

What happened? What was said or done?*

eXamPLe 3Date that it happened* (DD/MM/YYYY)

Name and position of the person who allegedly behaved this way*

Relationship of this person to you. For example co-worker, person I supervise, supervisor, manager, owner*

Name/position of any witnesses*

What happened? What was said or done?*

SecTion 3: acTionS Taken by you To reSoLVe THe iSSue1. Have you checked whether your workplace has a bullying policy and reporting procedure?*

Yes No

2. Have you spoken to the other person and told them that you object to their behaviour and asked that it stop?*

Yes No

3. Have you reported it at work (verbally or in writing)?*

Yes NoIf YES, did you:3a. tell your health and safety or union representative?

Yes NoIf YES, what is their name?

3b. tell your supervisor?

Yes No

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If YES, what is their name?

3c. Use your workplace reporting procedures?

Yes No N/AIf YES, what was the name of the procedure? What did you do?

If NO, is it because:i. There are no workplace procedures

Yes Noii. You are concerned for your safety

Yes Noiii. The person doing the alleged bullying is the most senior person in the workplace

Yes No

SecTion 4: acTionS Taken by your WorkPLace To reSoLVe THe iSSue4. Did your workplace respond to your report of alleged workplace bullying?

Yes No I did not report it4a. If YES, did your workplace make enquiries into, or investigate, your allegations?

Yes – made enquiries Yes – investigated No Other If other, please specify

4b. Who made the enquiries, asked questions or conducted the investigation?

4c. Were you informed of the outcome of the enquiries or investigation?

Yes NoIf YES, what was the outcome?

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SecTion 5: your HeaLTH anD SaFeTy5. Are you currently at work?*

Yes No

6. Have you had time off work and/or sustained an illness or injury as a result of this issue?*

Yes No

7. Have you sought medical treatment as a result of this issue?*

Yes No

8. Do you have a Certificate of Capacity from your doctor as a result of this issue?*

Yes No

9. Have you been admitted to hospital as a result of this issue?*

Yes No

10. Have you lodged a workers compensation claim?*

Yes No

SecTion 6: oTHer WorkPLace iSSueS11. Are you being formally performance managed at work?*

Yes No

12. Are you facing disciplinary action at work?*

Yes No

SecTion 7: oTHer JuriSDicTionS13. Have any of the following organisations been involved in resolving this matter? (tick any that apply)

NSW Police NSW Anti-Discrimination Board Union

NSW Ombudsman Fair Work Commission Office of Industrial Relations

What action have they taken?

SecTion 8: conTacTing SaFeWork nSW14. What is your reason for contacting SafeWork NSW about this issue?*

I am concerned for my safety

I am still being bullied

The person doing the alleged bullying is the most senior person in my workplace

Other people at my work are being bullied by the same person

My workplace doesn’t have policies and procedures for preventing and responding to workplace bullying

My workplace did not respond when I reported the alleged bullying

My workplace responded but not in accordance with the workplace policies and procedures

My workplace responded but did not make enquiries or investigate all of my allegations

My workplace responded but did not communicate the process to me

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My workplace responded but did not communicate the outcome to me

My workplace responded but the person who made the enquiries or investigated was not neutral

My workplace responded but they have not checked whether the alleged bullying has stopped

OtherIf other, please specify

What outcome would you like to see as a result of raising this issue with SafeWork NSW?*

Catalogue No. SW08589

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Locked Bag 2906, Lisarow, NSW 2252 | Customer Experience 13 10 50 Website www.safework.nsw.gov.au