Fill - Free fillable Human Resources Reporting Statement Fill In (Edmonds Community College) PDF form

HUMAN RESOURCES

REPORTING STATEMENT

(Turn in the completed and signed Reporting Statement to the Human Resources Office, Clearview Building.)

oday’s Date: _________________________________ Campus ID#: _________________________________________

Last Name, First Name: ______________________________________________________________________________

Campus Email: ________________________________ Personal Email: _______________________________________

Campus Phone: _________________________ Cell Phone: ____________________ Home Phone: _________________

Address: __________________________________________________________________________________________

City: _________________________________________ State: ___________ Zip Code: __________________________

I am a ______ Student _____ Employee _____ Visitor/Other (specify) ________________________________

Location of Incident (be specific): ______________________________________________________________________

Date of Incident: ______________________________ Time of Incident: ______________________________________

I am reporting the following – check those that apply:

_____ Title IX Violation _____ Sexual Harassment _____ Workplace Harassment

_____ Supervisor/Employee Concern _____ Student Concern _____ Assault/Altercation

_____ Unsafe Condition _____ Stalking _____ Threat

_____ Ethics Violation _____ Discrimination _____ Workplace Violence

_____ Accident

_____ Employee/Student Conduct _____ Theft/Missing Item(s)

_____ Other _______________________________________________________________________________________

My Role: _____ Victim _____ Witness _____ Other (specify): _______________________________________

Names/Contact Information for Witnesses, if any:

__________________________________________________________________________________________________

Please describe the incident or concern, providing who, what, where, when, and how

as clearly as possible. Attach a

Supplemental Reporting Statement if more room is necessary.

__________________________________________________________________________________________________

I certify and declare under penalty of perjury under the laws of the State of Washington the above statements are true and accurate.

ignature: ___________________________________________________________ Date: ________________________

opies, if deemed appropriate by Chief Human Resources Officer or Designee: BIT; Campus Safety and Security, Student Conduct Officer Rev. 1/2016

HUMAN RESOURCES

SUPPLEMENTAL REPORTING STATEMENT

Continuation of Reporting Statement – Page # _____ of _____ (Total # of Pages)

Today’s Date: ____________________________________ Campus ID#: ______________________________

Last Name, First Name: ______________________________________________________________________

Continue to describe the incident or concern, providing who, what, where, when, and how as clearly as possible.

Attach additional Supplemental Reporting Statements if more room is necessary.

__________________________________________________________________________________________________

I certify and declare under penalty of perjury under the laws of the State of Washington the above statements are true and accurate.

Signature: ___________________________________________________________ Date: ________________________

Copies, if deemed appropriate by Chief Human Resources Officer or Designee: BIT; Campus Safety and Security, Student Conduct Officer Rev. 1/2016

Fill Online, Printable, Fillable, Blank Human Resources Reporting Statement Fill In (Edmonds Community College) Form