work ENVIRONMENT INCIDENT REPORT FORM Your Name(Required) First Last Today's Date(Required) MM slash DD slash YYYY Please describe the nature of your submission:(Required)Violation of policy or protocol as indicated in the employee handbook.Uncertain/Does not violate policy or protocol as indicated in the employee handbook, but I still wanted to report it.OtherWas this as one-time event or ongoing?(Required)One-timeOngoingDate this Issue Occurred(Required) MM slash DD slash YYYY Date this Issue Began(Required) MM slash DD slash YYYY Date of Most Recent Recurrence(Required) MM slash DD slash YYYY Did this incident involve just yourself, yourself and other employees, or just other employees?(Required)Just myselfMyself and other employeesJust other employeesPlease list all employees involved, separating names by commas.(Required) Example: Myself, John Smith, Jane DoeDid this incident involve clients or other non-employees in the office space?(Required)YesNoPlease list all clients or other non-employees involved, separating names by commas.(Required) Example: Bob Smith (Emily's client), Janet Doe (contractor for carpet cleaning)Please describe the exact incident you wish to report. Be as concrete and descriptive as possible.(Required)Attestation Regarding Communication(Required) I have read the below and understand.All complaints submitted in writing will be investigated and kept confidential to the extent possible, including the submission of this form, which at the outset is only sent to the Managing Director. Individuals who make complaints have an obligation to assist and cooperate with any subsequent investigations. Change, Inc. cannot take the appropriate steps to remedy issues if it is unaware that they are occurring. It is each employee’s responsibility to report incidents about which the employee becomes aware. Anonymity is not guaranteed.Attestation Regarding Personnel Involved(Required) I have read the below and understand. The incident I'm reporting is appropriate to relay to the Managing Director because it does not concern the Managing Director's conduct/actions.In general, all incident reports are filed to the Managing Director per company policy. This includes not only supervisor/subordinate actions, but also actions between coworkers, vendors, clients, or other non-employees. If you believe it is inappropriate to discuss the matter with the Managing Director, you may gather the information designed to be collected in this form and provide it directly via email to any other Director, their Change, Inc.-provided Clinical Supervisor, or the CEO. CAPTCHA Δ
