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Metro Home Building Centre – Staff

Harassment Incident Report Form

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Date of Incident(Required)

MM slash DD slash YYYY

Time of Incident

Hours

:

Minutes

AM/PM

Name of Employee Involved/Witness(Required)

Department

Location of Incident(Required)

Nature of Harassment

What was said or done

Supervisor Informed

Yes

No

This report filed with Management?

Yes

No

Investigation to be conducted?

Yes

No

Are Measures in place to prevent a recurrence

Yes

No

Action Taken

Information about the perpetrator

Customer

Employee

Ex-Employee

Delivery Person

Contractor

Other

Name of perpetrator, if known

Please provide and further information that you think is relevant