Employee Information
Name of Employee:__________________________________________________________
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? Yes No
If yes, specify which policy and how the incident violated it. ___________________________
____________________________________________________________________
____________________________________________________________________
Action Taken
What action will be taken against the employee?____________________________________
____________________________________________________________________
____________________________________________________________________
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: __________________________________________________