ࡱ> 362 lbjbj22 ~"P_P_ _TT$   PZv$ ($j'''j''''.'o0'5''H'dTX : UNIVERSITY OF COLORADO DENVER WORKPLACE INCIDENT REPORT Name of Complainant: _______________________________________________ Department Name: _________________________________________________ Address: _________________________________________________________ Work Phone: ________________________Home Phone:___________________ Supervisors Name: ________________________________________________ INCIDENT INFORMATION: Date of Incident: _______________Time of Incident: _______________AM / PM Location of Incident:_________________________________________________ Nature of Incident: __________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Use additional pages if needed) Name of the Individual(s) involved: ____________________________________ Male: ___________ Female: ___________ Employer: ______________________ Name of other Individual(s) involved: ____________________________________ Male: ___________ Female: ___________ Employer: ________________________ Name of other Individual(s) involved: ______________________________________ Male: ___________ Female: ___________ Employer: ________________________ Any other Description: _________________________________________________ Name of Witnesses: ___________________________________________________ What the Complainant believes witnesses observed: _________________________ ______________________________________________________________________________________________________________________________________ Have the Police been contacted? ________YES________NO If Yes, which Police Department? UCHSC_____AURORA____DENVER______ AURARIA _______ OTHER (please specify): _____________________________________________ Statement by the Complainant: I ___________________________have read and reviewed the statements that are contained on this form and to my knowledge they are complete and accurate. Signature:________________________________Date:_____________________ Name of Interviewer: ___________________________Department: __________ Signature:________________________________Date:__________     Exhibit A  PAGE \* MERGEFORMAT 5 Exhibit A  PAGE \* MERGEFORMAT 5  !<=  B H R S G H ] ' . /  _ ` ²|mh%h>),CJOJQJaJhz CJOJQJaJh%hz CJOJQJaJh;bCJOJQJaJh%hCJOJQJaJh%h5CJOJQJaJh%h{X5CJOJQJaJh{X5CJOJQJaJh{Xh{X5CJOJQJaJh{Xh5CJOJQJaJ* !<=  R S G &d7$8$H$Pgd 7$8$H$gd $7$8$H$a$gd 7$8$H$gd{X $7$8$H$a$gd{XG H / ` efHI' X h7$8$H$]hgd{X 7$8$H$gd efCFHIo&'gk*+;<=>   hP-%hh{Xh{XCJ OJQJaJ h%h{XCJOJQJaJhCJOJQJaJh{XCJOJQJaJh%hCJOJQJaJD*+;<=>  gdP-%gd 7$8$H$gd  "#$;<=>?@AKLMdefghijklh \mHnHujhP-%UmHnHuhP-%mHnHujhP-%Uh \hP-%hA5jhA5U""#?@AKLhijkl$a$$a$gdP-%gdP-%E 000P1F:pP-%/ =!"#$% Dp5 01h:pP-%/ =!"#$% x02&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List FV F z FollowedHyperlink >*B* ph4@4 P-%Header  H$6/6 P-% Header CharCJaJ4 @"4 P-%0Footer  H$6/16 P-%0 Footer CharCJaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y el "G" 5@^^^^^^^a l G l /1@XZa!!8@0(  B S  ?         # > L g j m 7> G m 33#&gj  ! # > ? A L g j m          # > L g j m   P-%>),A5>DT \;b.Vg!o{Xz  @ml @UnknownG.[x Times New Roman5^Symbol3. .[x Arial;[xPHelveticaC.,*{$ Calibri Light7.*{$ CalibriA$BCambria Math"1h\'\'f f 4  2QHP ?2!xxFmI  UNIVERSITY OF COLORADO AT DENVERfmontoyaRovno, Samantha Oh+'0 (4 T ` lx'$UNIVERSITY OF COLORADO AT DENVER fmontoya Normal.dotmRovno, Samantha2Microsoft Office Word@@d@df  ՜.+,D՜.+,T hp  ' UCDHSC DDC  !UNIVERSITY OF COLORADO AT DENVER Title(iq}PublishingExpirationDatePublishingStartDate'  !#$%&'()+,-./0145K8I:;<=>?@ABCDEFGHJRoot Entry F71TableWordDocument ~"SummaryInformation("DocumentSummaryInformation8*MsoDataStoreTZEUWGL0A==2 Item PropertiesOBWGU401IA==2 Item  9KProperties F DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. metaAttributes"/>  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89qCompObjr