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 06 of 53 8 Doc u m e n t Identif icat ion F R M 038 P age Nu m b e r 2 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 Did y ou tell an y on e a bou t y our e x pe rie n c e a fte r th e a ll e g e d incide nt s Ye s No I f y e s pl e a s e prov ide the ir na me s Did y ou spe a k to t he pe rs ons na med in thi s re por t about the a ll e g e d viol e n c e a ndor h a ra ssm e nt Did y ou tell hi m he r to stop Ye s No I f y e s wh a t wa s hi sher r e sponse C ompl a inant S ig na ture Da te P rint Na me J ob Tit le I a tt e st t ha t t he infor ma ti on I ha v e prov ided is a t rue a nd a c c u ra te d e sc ript ion of m y c ompl a int a nd that I ha ve not wil lfull y or d e li be ra tel y mad e fa lse stat e ments I und e rsta nd that B E L TERR A CORP proh ibi ts a n y indi vidual f rom r e tal iating a ga inst me f or f il ing a c ompl a int a nd that I a m t o noti f y m y im media t e supe rvisor or B ra n c h Ma na ge r or R VP or if n e c e ssar y the Huma n R e sou rc e s De pa rtme nt a t t he C or pora te He a d O ff ice th a t I a m a victim of r e taliation S ig na ture o f the Author iz e d P e rson Rec e ivi ng C o mpl a int Da te P rint Na me J ob Tit le