Anonymous Employee Reporting Form

Incident Details

Date of Incident

MM slash DD slash YYYY

Time of Incident

Hours

Minutes

AM/PM

Type of Incident

Hostile Work Environment

Sexual Harassment

Bullying

Intimidation

Theft/Suspected Theft

Unsafe Working Conditions

Near Miss

Accident

Injury

Whistle-blowing

Discrimination

Harassment

Other

Description of Incident

Please provide a detailed summary of what occurred. Include what happened, how it happened, who was involved (if known), and any specific behaviors or comments relevant to this situation.

Witness

Were there others present or who are aware of this incident or situation?

Yes

Unknown

Please describe their involvement or what they may have observed.

If willing, please provide names of witnesses for interviewing.

Outcomes and Actions

Was there any injury, damage or immediate consequence?

Was there any actions taken by others (supervisory response, intervention, first aid)?

Context or Continued Pattern

Has this happened before?

Yes

Please provide information which may be relevant (how often has this happened, how long has this been ongoing, do you believe this is an ongoing issue)

Additional Notes

Is there anything else you believe should be known or considered in evaluating this report?

Follow-up

This report will be reviewed by the Chief Executive Officer and appropriate actions will be taken according to the information provided herein and that can be gathered after the review of this report. If you would like to be informed of the response please provide your name and preferred contact method.

Yes, I would like someone to follow up with me

Name

Preferred Contact

Phone or email address

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