EMPLOYEE INFORMATION

Employee's Name _________________________________________________________________________ Employee’s Job Title: _________________________________________________________________________

INCIDENT INFORMATION

Date/Time of Incident: _________________________________________________________________________ Location of Incident: _________________________________________________________________________ Description of Incident: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Witnesses to Incident: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Was this incident in violation of a company policy?    _____ No         _____Yes If yes, specify which policy and how the incident violated it. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

ACTION TAKEN

What action will be taken? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Has the impropriety of the employee’s actions been explained to the employee? _____ Yes  _____No Did the employee offer any explanation for the conduct?  If so, what was it? _________________________________________________________________________ _________________________________________________________________________ Signature of person preparing report: _________________________________________________________________________ Date: _____/_____/_____