R2017-149 Adopting Policy Prohibiting Sexual Harassment

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City of Decatur Workplace Incident Report Form Victim's Re ort 1. Victim's Name: 2. Job Title: 3. Address: 4. City: ST Zip: 5. Home Phone: 6. Work Phone: 7. Work Location: 8. Work Address: 9. Department: 10 Division: 11. Incident Date: 12. Incident Time: 13. Incident Location: 14. Type of Incident: (See definitions on reverse side)(Check one): [j Assault Criminal Damage to Property [I Disorderly Conduct j Harassment []Larceny Ij Menacing ® Reckless Endangerment Robbery Sex Offense rjSexual Harassment rIDiscrimination Other Please Specify) 15. Injuries to victim? Yes No 16. 1 Treatment Location: 17. Describe injuries: 18. Did police respond to incident? rl Yes No F25. Police Agency: 20. Police report filed? Yes No Police Report# 22. Was supervisor notified? Yes No Su ervisor's Name: 24. Union/em to ee re notified? Yes No N/ARe resentative's Name: 26. Alleged Assailant/Perpetrator(check one): i]Intruder Citizen 11 Customer L'j Visitor 11 Co-Worker [] Former Employee [] Supervisor 1I Relative Ij Friend/Acquaintance rl Arrestee/Detainee 0 Other Pleasespecify): 27. Alleged Perpetrator's Name: 28. Aile ed Per etrator's Age if known): 29. Address if known): 30. 1 citv. ST Zi 31. Brief Description of the Incident: 32. Did incident involve a weapon? Yes 11 No Description of weapon: 33. Was inappropriate action/violence directed only at one victim? 11 Yes fj No 34. Was victim alone when the incident occurred? j1 Yes [I No List other victims/witnesses: 35. Did victim have any reason to believe that an incident might occur? L1 Yes Ij No If yes,why? 36. What can be done to prevent a future similar incident? 37. The victim's confidentiality will be protected as much as practical and this information will be shared on a need to know basis only. 38. Victim's Signature: 39. Date: 40. Si nature of person preparing this form if different than victim): 6