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UNACCEPTABLE BEHAVIOR INCIDENT REPORT FORM INSTRUCTIONS This form must be completed by the complainant s supervisor or by UHR when an employee reports an incident involving a threat act of intimidation violence or other unacceptable behavior being committed by another employee. 1. Complainant s name Job Title 3. Home phone number Work phone number 4. Department 6. Incident date Incident time Incident location 7. Type of incident circle one Assault Robbery Harassment Disorderly Conduct Sex Offense Other. Please specify 8. Were you injured circle Yes No If yes please specify your injuries and the location of any treatment 9. Did police respond to incident 10. Which police department 11. Police report filed 12. Was your supervisor notified 13. Supervisor s name 14. Was any action taken specify 15. Alleged perpetrator circle one Intruder Customer Patient Resident Client Visitor Student Co-Worker Former Employee Supervisor Family/Friend Other specify 17. Please briefly describe the incident 18. Were you alone when the incident occurred 19. Provide information for all witnesses name department address phone number 20. Did the incident involve a weapon No Specify 21. Were you unable to continue or report for work due to the incident How long Why 22. Was the violence directed solely at you or were others included If others were included name s department s address es phone number s if known 23. Did you have any reason to believe that an incident might occur 24. Has this type or similar incident s happened to you or your co-workers Yes 25. Was the alleged assailant involved in previous incidents 26. Have you had any counseling or support since the incident 27. What are your recommendations for avoiding such an incident 28. Are there any measures in place to prevent similar incidents 29. Has corrective action been taken 30. Incident disposition Circle all that apply No action taken Arrest Warning Suspension Reprimand Other 31. Comments Action taken Referred to OUPD Referred to University Human Resources for further action Interviewed all parties investigated facts filed with UHR Dismissed complaint because Other Recorder s Signature Date Complainant s Signature. 1. Complainant s name Job Title 3. Home phone number Work phone number 4. Department 6. Incident date Incident time Incident location 7. Type of incident circle one Assault Robbery Harassment Disorderly Conduct Sex Offense Other. Please specify 8. Type of incident circle one Assault Robbery Harassment Disorderly Conduct Sex Offense Other. Please specify 8. Were you injured circle Yes No If yes please specify your injuries and the location of any treatment 9. Were you injured circle Yes No If yes please specify your injuries and the location of any treatment 9. Did police respond to incident 10. Which police department 11. Police report filed 12. Was your supervisor notified 13. Did police respond to incident 10. Which police department 11. Police report filed 12. Was your supervisor notified 13. Supervisor s name 14. Was any action taken specify 15. Alleged perpetrator circle one Intruder Customer Patient Resident Client Visitor Student Co-Worker Former Employee Supervisor Family/Friend Other specify 17.

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Keywords relevant to Behavior Incident Report Form

  • intimidation
  • Recorders
  • specify
  • disorderly
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