A free template you can use today
Prepared by Kirokune / AMA CLASS, K.K. · Updated September 7, 2026
https://kirokune.com/en/guide/#record-template

If you are trying to document workplace bullying or another concern, start with one event. Copy these prompts into your own notes, or download the blank text file. You can use it without Kirokune or an account. This is a personal worksheet, not an official complaint form.

When it happened
Date, time and time zone. Mark an approximate time as approximate.

________________________________________

When you wrote this note
Keep the writing date separate, especially when recalling an earlier event.

________________________________________

Place or channel
Where it happened, or the email or chat conversation involved.

________________________________________

People present
Names or initials you will recognize. Note who directly saw or heard it.

________________________________________

What you observed
Describe the actions and words. Separate an exact quote from your recollection.

________________________________________

Your response and what happened next
Include your own reply and the next action, if you remember them.

________________________________________

Impact and feelings
Record how it affected you, separately from what you observed.

________________________________________

Related material and unknowns
Where to find the original message or note. Mark gaps instead of filling them in.

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A personal record cannot determine whether something is harassment or how it will be treated in a process. Check the requirements of the person or service you decide to consult. This template is for editing in your own notes; it is not a chat-import file.