HTML Preview Employee Behavior Incident Report page number 1.
UNACCEPTABLE BEHAVIOR INCIDENT REPORT FORM
INSTRUCTIONS
This form must be completed by the complainant’s supervisor or by UHR when an employee
reports an incident involving a threat, act of intimidation, violence or other unacceptable behavior
being committed by another employee.
1. Complainant’s name: Job Title:
2. Complainant’s home address
3. Home phone number: Work phone number
4. Department
5. Complainant’s work location
6. Incident date: Incident time: Incident location:
7. Type of incident: (circle one): Assault, Robbery, Harassment, Disorderly Conduct, Sex
Offense, Other. (Please specify)
8. Were you injured? (circle) Yes No
If yes, please specify your injuries and the location of any treatment:
9. Did police respond to incident: Yes No
10. Which police department:
11. Police report filed: Yes No
12. Was your supervisor notified? Yes No
13. Supervisor’s name:
14. Was any action taken? (specify)
15. Alleged perpetrator: (circle one): Intruder, Customer, Patient, Resident, Client, Visitor,
Student, Co-Worker, Former Employee, Supervisor, Family/Friend, Other, (specify):
16. Alleged perpetrator – Name/address/age (if known):