Human Rights

HARASSMENT COMPLAINT REPORT FORM

for use with
Policy 23A: PSAC Anti-Harassment Policy: The Workplace
& Policy 23B: PSAC Anti-Harassment Policy: The Union

This form is intended to assist in the assessment of complaints of harassment. It will be used to assist the union to determine who to represent and on what basis under Policy 23A and to determine how to address allegations of harassment in our Union under Policy 23B. It should be treated as "Highly Confidential" and only be available to the following individuals:

• Complainant
• Respondent
• Witnesses (their own statements only)
• Local committee or individual assigned to investigate the situation under Policy 23A
• Harassment Complaint Committee under Policy 23B
• Officer Responsible under Policy 23B
• Appropriate Component or Alliance Officers responsible for appeals

While you may already use a form to assist in cases of harassment, we encourage you to use this form, which has been specially developed to assist you in the implementation of Policies 23A and 23B.

The form consists of five parts:

Part A: Complaint Identification

Part B: Complainant's Allegation(s)

Part C: Respondent Response to the Allegation(s)

Part D: Witness Statements

Part E: Harassment Complaint Committee Report

Part A: Complaint Identification

_____ Complaint is workplace related and this investigation is taking place under Policy 23A.

_____ Complaint is union related and this investigation is taking place under Policy 23B.

_____ The complaint took place in both a union and workplace context and this investigation will be used in the implementation of both Policy 23A and Policy 23B.

_____ The facts presented do not fall under either Policy 23A or Policy 23B.

Complainant's Name: ____________________________________

Respondent's Name: ____________________________________

Name of Investigator(s)/Harassment Complaint Committee Members

__________________________________________________________________
_________________________________________________________________

Name of Harassment Complaint Coordinator (if this complaint is related to Policy 23B)

_____________________________________________________________

Reference Number or Name for Complaint: ___________

PART B: Complainant's Allegations

1. Identifying information on complainant(s)

Name:________________________________________________________

Mailing Address:_______________________________________________

_______________________________________ Postal Code: __________

Telephone: (w) ___________________ (h) _______________________

How to contact while at the event: __________________________

_______________________________________________________________

Union Local: ____________________ PSAC Member No.: ___________

Other: ________________________________________________________

_______________________________________________________________

2. Identifying information on the respondent(s)

Name: ________________________________________________________

Contact Information for Respondent (whatever information the complainant can provide, e.g., phone number, work location, how to contact at the event, and so on)

______________________________________________________________

3. Details of the incident(s) giving rise to the complaint (use a separate piece of paper if necessary)

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4. Is the complainant the person who experienced the harassment?

Yes ___ No ___

5. Witnesses

List the names and contact information for possible follow up, either at the event or afterwards. Include any person the complainant requests be interviewed. This list may include those who were present for the incident or those to whom the complainant spoke after the incident (note whether present or not). Attach a copy of the list of participants, as required.

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

6. Why is this considered "harassment"?

(Use complainant's own words, noting in particular any comments of the complainant on prohibited grounds).

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

7. Impact on the individual/environment (in the complainant's words)

______________________________________________________________
_______________________________________________________________
_______________________________________________________________

8. Corrective action (what does the complainant want/need to resolve the situation)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

9. Signature of complainant

Note: If there are any changes to the form, the complainant must initial each change.

"I have read, I understand and I agree with the above information."

_______________________________________________________________
Complainant Date

_______________________________________________________________
Witness to signature Date

PART C: Respondent's Response

1. Identifying information on respondent(s)

Name: _______________________________________________________________

Mailing Address: ______________________________________________

____________________________________ Postal Code: _____________

Telephone: (w)____________________ (h) _______________________

Union Local: _____________________ PSAC Member No. :_________

Other: _______________________________________________________

_______________________________________________________________

2. Response to complaint (use a separate piece of paper if necessary):

______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

3. Witnesses

List the names and contact information for possible follow up, either at the event or afterwards. Include any person the respondent requests be interviewed. This list may include those who were present for the incident or those to whom the complainant spoke after the incident (note whether present or not).

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

4. Response to corrective action requested:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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_______________________________________________________________
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_______________________________________________________________

5. Agreed to actions:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

______________________________________________________________
_______________________________________________________________

6. Signature of respondent:

Note: If there are any changes to the form, the respondent must initial each change.

"I have read and understood the allegations. I agree to undertake the above mentioned actions on the understanding that this will constitute a full resolution of the complaint."

_______________________________________________________________
Respondent Date

_______________________________________________________________
Witness to signature Date

PART D: Witness Statements (Use a separate witness statement for each witness)

1. Identifying information on witness(es)

Name: ____________________________ PSAC Member No._________

Telephone: (w)____________________ (h) _______________________

Relationship to Complainant/Respondent (e.g., co-worker, friend and so on)

_______________________________________________________________

2. Statement about what the witness saw or heard pertaining to the incident in question. Note whether the witness was present at the incident or not. (Use a separate piece of paper if necessary)

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

3. Signature of witness:

Note: If there are any changes to the form, the witness must initial each change.

"The information I have provided in this statement is true."

_______________________________________________________________
Witness Date

_______________________________________________________________
Witness to signature Date

Part E: Report of the Local Committee/Individual Investigating Complaint (Policy 23A) or

Harassment Complaint Committee (Policy 23B)

1. Steps followed by those responsible for investigating the complaint (e.g., interviews conducted, consultation with resource persons/convenor, follow up)

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

2. Recommendations for Action in the Matter Under Consideration

(include rationale)

_______________________________________________________________
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3. FOR POLICY 23B ONLY: List and describe any steps undertaken to establish and preserve a harassment-free environment, e.g., distribution of policy/statement; introduction of the policy at the event; any intervention by person(s) responsible for the event, or others; previous complaint (informal or otherwise).

_______________________________________________________________
_______________________________________________________________
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4. Recommendations for changes to the relevant PSAC policy, guidelines, complaint form (use additional paper if necessary).

_______________________________________________________________
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5. Signature of those responsible for investigating complaint:

"The information I have provided in this statement is true."

_______________________________________________________________
Print Name Signature Membership No. Date

_______________________________________________________________
Print Name Signature Membership No. Date

_______________________________________________________________
Print Name Signature Membership No. Date

_______________________________________________________________
Print Name Signature Membership No. Date