Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 5 05 of 53 8 Workpl ace Vi ol en ce Bu ll y i ng Harass ment Compla in t F orm Doc u m e n t Identif icat ion F R M 038 P age Nu m b e r 1 of 2 Doc u m e n t C r e ation Dat e J une 15 2013 Im p le m e n tat ion Dat e J ul y 01 2013 W orkpla c e Violenc e B ul l y in g Ha r a ssm e nt C ompl a int F orm This for m i s to b e use d to docume nt an y c laims of viol e nc e bull y in g a ndor ha ra ssm e nt i nc ludi n g se x ua l ha ra ssm e nt whic h o c c ur s in t he wor kplac e To e n sure that a ll viol e nc e bul l y in g a ndor ha ra ssm e nt c ompl a int s a re man a g e d a pp ropr iate l y e ff e c ti ve l y a nd in a c c orda nc e with t he C ompan y s polic y viol e n c e bul l y in g a ndor ha ra ssm e nt complaints i nc ludi ng se x ua l har a ssm e nt complaints will be re c orde d usi n g thi s for m Onl y those indi viduals a uthoriz e d to re c e iv e suc h c ompl a int s ma y do so I f ne e de d g ui da nc e c a n be obt a ined f r om Human R e sourc e s Na me of C ompl a inant Na me s o f indi vidual suspec ted of viol e nc e bull y i n g a ndor ha r a ssm e nt the R e sponde nt L oc a ti on P lea se de sc rib e the spe c ific incide nt of viol e nc e bull y in g a ndor ha ra ssm e nt allege d De sc ribe e a c h incide nt sepa r a tel y including the da t e ti me a nd loca ti on Use a ddit ional pa g e s if n e c e ssar y Did a n y on e witness the a ll e g e d viol e n c e bull y in g a ndor ha r a ssm e nt Ye s No I f y e s pl e a s e prov ide the ir na me s Ar e ther e other s who m a y ha v e e x pe rie nc e d si mi lar a ll e g e d viol e n c e a ndor ha ra ssm e nt b y the indiv idual na med a bove Ye s No I f y e s pl e a s e prov ide the ir na me s