Section 1: Your Details
Section 2: About the Discrimination
Section 3: Context of the Incident
Section 4: Impact on You
Section 5: Previous Actions Taken
Section 6: What You Need
Section 7: Confidentiality
(Optional—you may remain anonymous, but providing details may help us investigate more effectively)
Do you wish to remain anonymous?
YesNo
"Enter your full name."
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What type of discrimination are you reporting? (Select all that apply)
AgeSex / GenderSexual Orientation / Gender IdentityRace / Ethnicity / NationalityReligionDisabilityPregnancy or Family ResponsibilitiesOther
Who engaged in this discriminatory behaviour?
—Please choose an option—Unknownknown
What is their relationship to you?
ManagerSupervisorCo-workerContractorClientOther
Has this behaviour occurred more than once?
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Where did the discrimination take place? WorkplaceRemoteOnlineClient siteOther
When did the behaviour occur?
Approximate time of the incident(s)
Were there any witnesses present? YesNo
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How has this behaviour affected you personally? EmotionallyPhysicallyProfessionallyOther
Have you experienced changes in your work performance, health, or wellbeing because of this behaviour?
Have you reported this discrimination before?
Have you spoken directly to the person about their behaviour?
Have you sought support from HR, a manager, or external services (e.g., Fair Work, Australian Human Rights Commission, EAP)?
What outcome would you like from this report?
InvestigationMediationNo further contactWorkplace adjustmentTrainingOther
Do you feel safe continuing to work in your current role/team while this matter is being addressed?
Do you want to be contacted for follow-up?
How would you prefer to be contacted?
—Please choose an option—EmailPhoneOther
Do you require immediate support (e.g., counselling, leave, workplace adjustment)?
