GENERAL STAFF INCIDENT REPORT FORM

DATE OF REPORT
EMPLOYEE NAME	TITLE
MANAGER NAME	TITLE

INCIDENT DETAILS

LOCATION	DATE OF INCIDENT	TIME
DESCRIPTION OF INCIDENT
EMPLOYEE EXPLANATION
WITNESSES
ACTION TO BE TAKEN select one
Verbal Warning	Probation	Dismissal
Written Warning	Suspension	Other
EXPLANATION OF ACTION TO BE TAKEN

By signing this form, you acknowledge that you have read and understood the information contained herein.

EMPLOYEE SIGNATURE	DATE	EMPLOYEE SIGNATURE	DATE

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