Sample form and steps for providing a notice of an occurrence of workplace harassment and violence

Step 1 – Review the definition of harassment and violence

As the principal party or a witness of an occurrence of harassment and violence, you must review the definition of harassment and violence:

The Canada Labour Code (the Code) defines harassment and violence as: “any action, conduct or comment, including of a sexual nature, that can reasonably be expected to cause offence, humiliation or other physical or psychological injury or illness to an employee, including any prescribed action, conduct or comment.”

Step 2 – Fill out the form

If you believe the occurrence meets the definition of harassment and violence, please fill out the Notice of an occurrence of harassment and violence form to the best of your ability and provide it to your employer or designated recipient. If you are a witness and wish to remain anonymous, do not provide your name on the form.

Notifying your employer or designated recipient verbally

If you prefer to verbally notify your employer or designated recipient of an occurrence instead of filling out the form, please provide them the information concerning each of the fields in the form. If you are a witness and wish to remain anonymous, you may provide the notice by phone or have another employee provide it for you.

Protection of privacy

[insert name of the person or unit that is designated to receive notices of an occurrence] will read the information provided in this form. They may share the information in the form with the responding party and/or an investigator or conciliator, if necessary. However, the names of the following will not be included in the report that an investigator may be required to produce:

• the names of the principal party
• responding party
• witnesses, and
• any other person who are involved in the resolution process to the occurrence

In the case of an emergency

If you believe that you or someone else’s life or physical safety is at risk, please initiate your emergency procedures by calling the Security Office at [insert phone number of the office that deals with emergency procedures] or 9-1-1.

As the principal party or witness, please provide the following information:

• First and last name
  • Note: if this is an anonymous notice, do not provide your first and last name
• Date(s) on which you experienced or witnessed the occurrence(s)
• Name(s) or a detailed description of the parties involved in the occurrence as well as their reporting relationships, if any
  • Note: If you do not provide enough information to identify the principal party, the employer can take no further action:
  • Detailed description of the occurrence(s) and include the applicable dates, if known
  • Attach other supporting documents

  

  Example form of notice of an occurrence of harassment and violence [PDF - 322 KB]