Name of Organization/Company/Department where incident happened
Your answer
Name of City/Town and Province where incident happened
Your answer
Date of incident (if multiple state first time you recall)
Your answer
Was the incident reported to the company
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Yes
No
Was the incident reported to the police
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Yes
No
Has the harassment stopped
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Yes
No
Option 3
Are there other woxmn in the company/organization/department who may have or still are experiencing similar treatment?
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Yes
No
Are you willing to speak with one of WISE's case assistants to assist in documenting your experience? *
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Yes
No
Not sure
Please share a telephone number where we can reach you; we will send a text message first before calling.
Your answer
If comfortable, please share your email address? (Note that this form will not automatically collect your email address)
Your answer
Would you like your case pursued within the company, CCMA or through the courts? *
Tell your story of what happened, state as much as you can remember and include names of supervisors who may have been involved, any witnesses, etc. (you may also keep names fictitious or anonymous). *
Your answer
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