“A Meaningful and Satisfying Life for All”
WORKPLACE HARASSMENT/VIOLENCE INCIDENT REPORT
The purpose of this report is to initiate an investigation around incident/incidents of workplace harassment occurring between KACL staff.
Please complete this report and forward it in a sealed envelope marked PRIVATE AND CONFIDENTIAL to your Manager with a copy to Human Resources at the Central Office(Lisa Thomassen or Carey Heron).
A formal confidential investigation will be initiated upon receipt of the completed/signed report
Date: __________________________________________ Time:____________________________
Location____________________________________________________________________________
Name of individual(s)directly involved in the incident ___________________________________________________
Witnesses:________________________________________________________________________________
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Description of the Incident (use additional pages if necessary)
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Employee’s Explanation of events:
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What impact has this conduct had on you?
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Recommendations (if any):
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Reported By: (Please Print):________________________________________________
Signature of Employee:_______________________________________________________
Report Received by:_________________________________________________________
Date of Report:___________________________________________________________
KACL takes every complaint of harassment very seriously. A person making a complaint is encouraged to provide as much information and detail as he or she can to assist us in handling the complaint.
Please note that a deliberate false or malicious complaint is considered to be a serious matter and subject to disciplinary action.