Section 1: Your Details
Section 2: About the Victimisation
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 action do you believe led to the victimisation? (Select all that apply)
Making a complaint (e.g., about harassment, discrimination, bullying, safety, or workplace rights)Supporting another worker’s complaintExercising a workplace right (e.g., requesting leave, union involvement, WHS reporting)Other
Who engaged in the victimising 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 victimisation occur? WorkplaceRemoteOnlineClient siteOther
When did the incident occur? Approximate time of the incident(s)
Were there any witnesses present? YesNo
How has this victimisation affected you personally? EmotionallyPhysicallyProfessionallyOther
Have you experienced changes in your work performance, health, or wellbeing because of this behaviour?
Have you reported this victimisation 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 Ombudsman, Australian Human Rights Commission, WHS regulator, 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?
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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)?
