Form

Bullying, Harassment and Discrimination Incident Form

Effective: January 2023

This form is for making a formal complaint about an occurrence of bullying, discrimination or sexual harassment within the AMA (WA) workplace, including work-related meetings and events.

Lodging a formal complaint also acknowledges that an investigation and response is sought.

If you do not want to make a formal complaint, please complete the Discrimination / Harassment / Bullying Incidents Notification Form.

Sexual harassment of a type that is criminal conduct by nature (e.g. physical molestation, sexual assault, indecent exposure, stalking, obscene communications) should also be reported to the Police.

Name (if you do not wish to provide your name write "Anonymous") *

Name of person(s) who has or is conducting the behaviour you are reporting.

Date of report *

Nominate the type of conduct that has occurred, or is occurring. *

Bullying

Discrimination

Sexual Harassment

Nominate a classification that best represents the person(s) you are reporting. *

AMA (WA) Employee

AMA (WA) Board member

AMA (WA) Committee

Please describe the conduct you wish to report, including when and where the conduct occurred and what was said or done. If the conduct occurred on more than one occasion, describe the frequency and for how long the conduct has been occurring. * Are there any other comments that you want to make about the incident? What outcome are you seeking to resolve the complaint? *