Anti-Bullying Incident Report
(This incident form shall be completed by all persons submitting a formal complaint under the City of Fort Bragg Anti-Bullying Policy. The City of Fort Bragg is committed to promptly and responsibly investigating all claims of workplace bullying in accordance with the Anti-Bullying Policy. Your cooperation in truthfully completing this form and providing as much accurate information as possible will enable the City of Fort Bragg to investigate and respond to these matters more quickly and efficiently.) Please CLEARLY PRINT the following information:
Please circle the appropriate answer describing the person reporting concern:
□City Employee/Complainant □Supervisor or Manager
Your Name: (Last, First name) _______________________________________________ Position or Title:_____________________________________________________________ Department:____________________________________________________________ Office Telephone: (_) _
Supervisor/Manager's Name:
Name of individual(s) or the Respondent(s) that you believe engaged in workplace bullying.
Address:
City: State: Zip Code:
When did the alleged bullying conduct occur? Date:_____________________________________ Where did the alleged bullying occur? Location:
Were there any witnesses to the bullying conduct? Yes_____ No If yes, please provide the witness name(s) and contact number(s).
Are there written documents or verbal recordings such as a phone messages? Yes_____ No _ Describe the documents and messages
_________________________________________________________________________________________ Describe in detail what happened. (Please write or type your response. You may attach additional pages, if necessary.) What corrective action do you believe would address your complaint? ___________________________________________________________________________________________ Have you previously reported this issue? Yes _____ No _______ If so, please describe the incident, when it occurred, and the outcome.
AFFIRMATION
I affirm that I have read the above charge(s) and that it is true to the best of my knowledge, information and belief.
Signature
You may forward the completed complaint form as applicable to either: City of Fort Braggy Office of Personnel, Employee/Labor Relations; and/or,
Date
FOR USE BY CITY OF FORT BRAGG PERSONNEL/EEO DATE FILED: RESOLUTION: _FOR USE BY CITY OF FORT BRAGG PERSONNEL/EEO DATE FILED: RESOLUTION: _
FOR USE BY CITY OF FORT BRAGG PERSONNEL/EEO
DATE FILED: RESOLUTION: _
FOR USE BY CITY OF FORT BRAGG PERSONNEL/EEO
DATE FILED: RESOLUTION: _
CONFIDENTIALCONFIDENTIAL
CONFIDENTIAL
CONFIDENTIAL