Eastern Michigan University Workplace Violence/ Prohibited Conduct Incident Report Form printable pdf download

Eastern Michigan University Workplace Violence/ Prohibited Conduct Incident Report Form

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

Pg. 1 of 2

Eastern Michigan University Workplace Violence/ Prohibited Conduct Incident Report Form