Workplace Incident Form

This form is to be completed when incidence occur on Health Sciences Center Property including threats, threatening behavior, or acts of violence involving University staff, faculty, or students. If an incident involves an outside party in Oklahoma City, please contact the Campus Police immediately at (405) 271-4911, and in Tulsa please contact Security at (918) 660-3333. This form is to be completed by the reporting party.

Type of Situation

Location

 Date/Time/Day/Occurred:

Date/TimeDay/Reported

Summary of Situation, Including all witnesses:

Reporting Party:

Date and Time:

Person(s) Involved:

 1. Name

Race: White Black Latin Indian Asian Other

Sex: Male Female

Age & Date of Birth:

Work Address:

Work Phone Number:

Home Address:

Home Phone Number:

2. Name

Race: White Black Latin Indian Asian Other

Sex: Male Female

Age & Date of Birth:

Work Address:

Work Phone Number:

Home Address:

Home Phone Number:

3. Name

Race: White Black Latin Indian Asian Other

Sex: Male Female

Age & Date of Birth:

Work Address:

Work Phone Number:

Home Address:

Home Phone Number:

Vehicle Information

Tag:

Year:

Color:

Make:

MODEL 2-Door 4-Door Sedan Coupe Pickup Convert. Unknown

Have there been previous incidences of violence: YES NO

If the answer to the previous question is YES, when?

Summary of Situation, including all witnesses:

Actions Taken:

Reporting Party:

Date and Time:

This box reserved for additional information if required:

Print this form, and send it via mail:

To: Oklahoma City Human Resources Attention: Cynthia Clegg, 1100 North Lindsay, (P.O. Box 26901), Oklahoma City, OK 73190. E-mail Cynthia-clegg@ouhsc.edu Telephone: (405) 271-2191, Fax: (405) 271-3925

To: Tulsa Human Resources Attention: Barbara Abercrombie, 4502 E. 41st St., Suite 1C114 Tulsa, OK. 74135. Telephone: (918) 660-3193, Fax (918) 660-3200