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 08 of 53 8 Doc u m e n t Identif icat ion F R M 039 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 W orkpla c e Violenc e B ul l y in g Ha r a ssm e nt R e sponse to C ompl a int F orm W a s ther e a n y one e lse in volved in the inc ident s Ye s No I f y e s pl e a s e pro vide the ir na me s Did the Com plaina nt spea k to y ou a bout y ou r be h a vior or a c ti on in t he incide nts Ye s No I f y e s wh a t di d he she sa y a nd wha t wa s y ou r r e sp onse W ha t wa s the int e nti on of y ou r be ha v io r or a c ti on in t he incide nts R e sponde nt 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 r e sponse to the c ompl a int made a g a inst me a nd th a t I h a ve not wil lfull y o r de li be ra tel y made f a lse stat e ments I unde rsta nd th a t B E L TERR A CORP proh ibi ts an y indi vidua l fr o m re taliating a g a inst a n e mpl o y e e for fili n g a c om plaint and that I will be subj e c t t o discipl inar y a c ti on if I mak e e n g a ge in an y a c ts of r e taliation ag a inst the Com plaina nt a ndor the witnesse s invo lved S ig na ture o f the Author i z e d P e rson Rec e ivi ng R e s ponse Da te P rint Na me J ob Tit le