1) Your Email
2) Have you ever been the victim of a bully?
Please answer Yes or No
3) Have you ever witnessed someone else being bullied at work?
Please answer Yes or No
4) What position did the bully hold in the company in relationship to the victim?
Please select...
Manager/supervisor
Subordinate
Peer
5) What form or forms did this bullying take?
Please select...
Public humiliation
Being shouted at
Deliberatly overloaded with work (set up to fail)
Unjustifiable discipline
Deliberate exclusion from social event
Spreading gossip or rumor
Constant insults, put downs, digs, cracks, etc.
Called at home, just to further intimidate
Vacation cancelled, just because
Hours of work or duties changed, just because
Sexual harassment
Other, please describe
If other please describe:
6) Where there has been workplace bullying, were there any complaints made about the bully to (please select one):
Please select...
The next level of management
Human Resources manager
Union representative
Other, plese specify below
If other, please describe:
7) Does your employer have a specific procedure to deal with workplace bullying (separate from Sexual Harassment)?
Please answer Yes, No or I don't know
8) If the answer to the question 6 was yes, does your employer:
Please select
Enforce policy
Ignore policy
9) Where workplace bullying had been identified and escalated through management, has your employer provided counseling to:
Please select....
the Bully
the Victim
Both Bully and Victim
Neither
10) Are you aware of anyone leaving your place of work as a result of workplace bullying?
Please answer Yes or No
11) Have you suffered any physical ailments from workplace bullying:
Please select....
Headaches
Depression
Fatigue
Hypertension
Muscle Tension
Intestinal ailments
Stomach ailments
Other or multiple, please describe
If other, please describe:
11) Are you male or female?
Please select...
Female
Male
12) Was the bulling you experienced or witnessed:
Please select.....
Male to Female
Male to Male
Female to Male
Female to Female
13) Which of the following do you think will be most effective in eliminating workplace bullying in YOUR FUTURE:
Please select...
Escalate the issue to management for support
Escalate the issue to HR for support
Participate in group training to prevent this
Get individual help in dealing with this
Quit my job
Other, please desribe below
For Other, please describe:
14) Please add any additional comments regarding your bully experience:
15) Please briefly describe your workplace culture: