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09/2025 REPORT OF WORKPLACE VIOLENCE Workplace Violence Policy 2-14 (Submit to Human Resources, Complainant Information Name: Job Title: Department: Supervisor: Description of Incident: Provide a detailed description of the incident(s), including date(s), and location(s). Describe in your own words the actions of all involved - attach additional pages if necessary. Name(s) of Witnesses: I understand that Human Resources will conduct an investigation of my report. A report of workplace violence, its investigation, the outcome of the investigation and any action taken relating to a specific employee is confidential. Dissemination of confidential information shall be limited to persons with a need to know in order to conduct an investigation and take appropriate corrective action. I hereby authorize dissemination of information regarding this report to other persons with a need to know. I acknowledge that I have read and understand the above statements and certify that all information I have provided is true to the best of my knowledge. Employee Signature: Date: Submitted to: Date: SIGN