Incident Report

Incident Reporting Form

Please use this form to report any workplace incidents or concerns. Your confidentiality will be respected. It is important to provide as much relevant detail as possible to ensure that the situation can be properly addressed.

Date of report(Required)

Name

First Last

Iif you wish to remain anonymous, you may leave this blank

Date of the incident (if applicable)

Incident Type(Required)

Harassment

Complaint

Safety Issue

Other (please specify)

Incident Type (Other)(Required)

Description of Incident/Concern:(Required)

Please describe the incident or concern in detail

Some suggestions for details which may be important:

Nature of the incident: Provide a clear description of what happened. Include any actions, behaviors, or events that occurred.
Individuals involved: Identify any individuals who were directly involved in the incident, including both the person reporting and any others who may have been present.
Impact: Describe the impact of the incident on yourself or others involved. This can include emotional, physical, or professional repercussions.
Documentation: If there is any supporting documentation or evidence (such as emails, messages, or photographs), mention it in the report or attach it if possible.
Any Actions Taken: If any actions were taken at the time of the incident or afterward (such as reporting to a supervisor or People Department/HR), include that in the information.
Desired Outcome: If there is a specific outcome or resolution that you are seeking, mention it in the report.

If available, please provide evidence:

Drop files here or

Max. file size: 2 GB.

Attach pictures of the incident. If video was taken please email that to us at contact@depalm.com.

Location of Incident (if applicable)

Describe where the incident took place. This can include specific departments, offices, or work areas.

Witnesses (if any, please provide names or details)

If there were any witnesses to the incident, mention their presence and provide their names if known.

Any Additional Information:

I prefer to be contacted for follow-up:(Required)

Yes

Preferred Contact Method

This field is for validation purposes and should be left unchanged.