Workplace Violence/ Prohibited Conduct Incident Report Form - Eastern Michigan University - Michigan

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Check here if additional documents or police report is attached.
Incident Report #________
Eastern Michigan University
WORKPLACE VIOLENCE/ PROHIBITED CONDUCT INCIDENT REPORT FORM
Date Reported:
Name of Person Making Report:
Telephone Number:
If anonymous, indicate method of notification:
Telephone call
Written document
Other; specify:
Name/Location of the affected Department / College :
Name of alleged person demonstrating
prohibited behavior:
Relationship to the Department/ College:
Employee
Student
Visitor
Vendor
Contractor
Relationship to Victim/Potential Victim (if any):
Name of Victim/Potential Victim:
Please attach additional sheets if necessary
When (date) and where (physical location) did alleged threat or act of violence/ prohibited behavior occur?
What events occurred immediately prior to the incident?
What was the specific language of the alleged threat/ prohibited behavior?
Provide specific details of the alleged threat or act of violence/ prohibited behavior:
Workplace Violence/Prohibited Conduct Incident Report
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Check here if additional documents or police report is attached.
Incident Report #________
Eastern Michigan University
WORKPLACE VIOLENCE/ PROHIBITED CONDUCT INCIDENT REPORT FORM
Date Reported:
Name of Person Making Report:
Telephone Number:
If anonymous, indicate method of notification:
Telephone call
Written document
Other; specify:
Name/Location of the affected Department / College :
Name of alleged person demonstrating
prohibited behavior:
Relationship to the Department/ College:
Employee
Student
Visitor
Vendor
Contractor
Relationship to Victim/Potential Victim (if any):
Name of Victim/Potential Victim:
Please attach additional sheets if necessary
When (date) and where (physical location) did alleged threat or act of violence/ prohibited behavior occur?
What events occurred immediately prior to the incident?
What was the specific language of the alleged threat/ prohibited behavior?
Provide specific details of the alleged threat or act of violence/ prohibited behavior:
Workplace Violence/Prohibited Conduct Incident Report
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Describe the conduct and appearance of the person demonstrating the alleged threat or prohibited behavior (physically and
emotionally):
Names of Witnesses:
Telephone Numbers:
#1
#2
#3
What happened to the person making the threat or demonstrating the alleged prohibited behavior after the incident?
Names of supervisory staff involved and how they responded:
Was Law Enforcement notified?
Yes
No
If yes, what action was taken by Law Enforcement?
No action taken
Report written
Suspect escorted from property
Suspect arrested
Name of local Law Enforcement Agency:
Report Prepared by:
Date:
Job Title
Phone No.:
Please send this Workplace Violence/Prohibited Conduct Incident Report Form to the appropriate Human Resources
Department (send to Staff HR for staff, graduate assistants and student employees or Academic HR for faculty and
lecturer employees)
THIS BOX TO BE COMPLETED BY HUMAN RESOURCES
Steps that have been taken to ensure the threat will not be carried out or the act of violence/prohibited conduct repeated:
Workplace Violence/Prohibited Conduct Incident Report
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Download Workplace Violence/ Prohibited Conduct Incident Report Form - Eastern Michigan University - Michigan

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