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Butthurt Form Template

Effectively Address Complaints with Our Butthurt Form

If you've felt offended or threatened, documenting your experience can be crucial for resolution. This Butthurt Form Template helps you communicate your concerns clearly and obtain support swiftly. It features essential questions for reporting incidents, promotes accountability, encourages a healthy dialogue, and can be customized to suit your needs-all while ensuring your privacy is respected. Explore the live template to start addressing your concerns effectively.

Use this Template (FREE) Live Preview
Full name
Email address
Phone number (optional)
Preferred contact method
Email
Phone
Either
Do not contact
Your relationship to this incident
I experienced it
I observed it
I am reporting on behalf of someone else
Prefer not to say
Date of incident
Where did it happen? (location or link)
Primary setting
In-person
Online (social media)
Online (forum or chat)
Workplace
School or university
Customer support interaction
Family or friends
Prefer not to say
Other
Please Specify:
Describe what happened
Links to relevant posts, messages, or evidence (optional)
Was any policy, guideline, or rule involved?
Yes
No
Who was involved? Select all that apply
Please Specify:
How often has this or something similar occurred?
Never
Rarely
Sometimes
Often
Always
How upsetting was this for you?
Not at all
Slightly
Moderately
Very
Extremely
Did this affect your work, school, or daily life?
Yes
No
Please describe any impact on you
What outcomes would be most helpful? Select all that apply
Apology
Clarification
Policy or rule change
Content removal or correction
Mediation or facilitated conversation
Formal complaint escalation
No action needed
Prefer not to say
Other
Please Specify:
Are we permitted to share this report with the involved party or relevant team?
Yes
No
May we contact you for clarification or updates?
Yes
No
I confirm the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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When to use this form

Use this lightweight form when someone feels slighted, mocked, or unfairly singled out during a chat, meeting, game, or club event. It helps you capture what happened, the tone, and the impact, so moderators or managers can respond and set clear norms. If the issue is about how a business treated you, route it to the Customer complaint form. If the report involves bias or harassment, use the Discrimination complaint form for a formal record. For loud neighbors or shared spaces, the Noise complaint form is a better fit. The result is a respectful log that cools tempers, guides mediation, and points people toward a fix.

Must Ask Butthurt Questions

  1. What happened, in your own words?

    An open summary captures context and tone, not just a label. Clear details help reviewers understand the incident and avoid assumptions.

  2. When and where did it happen?

    Time and place let you verify facts and spot patterns. This also helps prioritize recent or repeated events.

  3. Who was involved or present?

    Listing people clarifies who was affected and who can verify what occurred. It also shows who to contact for follow-up.

  4. How did the situation affect you or your work?

    Describing impact (stress, lost focus, missed task) helps gauge severity. It guides what support or action is appropriate.

  5. What outcome would feel fair to you?

    Stating a desired resolution speeds decisions and sets expectations. It surfaces options like an apology, mediation, or a policy reminder.

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