FREE CLAIM REVIEW FOR SEXUAL HARASSMENT IN THE WORKPLACEFull Name*Phone number*Email* How did you hear about us?*Form of Behaviour – select the most appropriateSexual HarassmentDiscrimination – Sex/Gender Identity/SexualityDiscrimination - Pregnancy/BreastfeedingDiscrimination – Relationship StatusDiscrimination – Family/Parental ResponsibilitiesDiscrimination - AgeDiscrimination – RaceDiscrimination – Injury/DisabilityDiscrimination – ReligionDiscrimination – PoliticalDiscrimination – UnionDiscrimination – Lawful Sexual ActivityVictimisationWhere did the behaviour take place?When did the behaviour take place?Provide a brief description of what has happened?Questions: Please select the reasons in which your discrimination/harassment occurs. (can select more than one)* Sex Relationship Status Pregnancy Parental Status Breastfeeding Age Race Impairment Religious Belief or Religious Activity Political Belief or Activity Trade Union Activity Lawful Sexual Activity Gender Identity Sexuality Family Responsibilities Association with, or relation to, a person identified on the basis of any of the above attributes Sexual Harassment Victimisation (targeted for making a complaint or supporting the complaint of another person) DISCRIMINATION: DESCRIBE WHAT HAPPENED Describe the events / what's happening?Do you think you’ve been victimised because you complained or supported a complaint about discrimination, sexual harassment or public vilification?Do you think you were asked unnecessary questions about one of the grounds listed?SEXUAL HARASSMENT: DESCRIBE WHAT HAPPENEDHow were you sexually harassed?Do you think you’ve been victimised because you complained or supported a complaint about discrimination, sexual harassment or public vilification?Do you think you were asked unnecessary questions about one of the grounds listed?TimeframesDate/s of incidents (List all)LocationWas employment a related factor? (ie conduct at work; conduct outside of work by a colleague/supervisor; work function)Who was the offender – Name, Position, Work relationship to prospectEvidence & Reporting Have you made any complaints to Human Rights Commission, Industrial Relations or other parties regarding anything included in this complaint?Have you made any complaints to your employer?Are you able to supply payslips/ or employment contract?Do you have an itemised diary of all the incidents?Do you have any witnesses? If yes, provide their namesDocumentary evidence? (ie texts, screenshots, emails etc)Has an investigation been conducted? (ie by an employer, department etc)Have you reported your concerns to a medical professional? If yes, provide detailsEmployment DetailsOccupationCompany NameDuration of employment with the companyHave you required time off as a result of the above discrimination/sexual harassment? If yes, please provide details of time offWere you dismissed/have you resigned from your position? If yes, please provide dates and detailsHave you lodged a Worker’s Compensation Claim? If yes, provide details (ie. status of claim, was the claim accepted/rejected?)NotesDo you have any other questions, concerns or information?
