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Basic form © James R. McDade (09-21-05) 209-667-2300 INCIDENT INVESTIGATION FORM Complainant: _______________________________ Accused: _______________________________Coordinating Investigator: _____________________________Nature of complaint being investigated: ___________________________________________________INVESTIGATION STEPS 1. Obtain and review a written statement (or “Employee Complaint Form”) from the Complainant. 2. List potential witnesses identified by Complainant.a. ___________________________________________ Interviewed Statement ObtainedIf not interviewed, describe why: _________________________________________________ 3. Obtain and review a written response from the Accused. 4. List potential witnesses identified by Accused.a. ___________________________________________ Interviewed Statement ObtainedIf not interviewed, describe why: _________________________________________________ 5. List other potential witnesses.a. ___________________________________________ Interviewed Statement ObtainedIf not interviewed, describe why: _________________________________________________ 6. List potential evidence that may exist.a. __________________________________________________ Obtained UnobtainableIf unobtainable, describe why: _________________________________________________ 7. Obtain copy of Company rules or procedures that may have been violated. 8. Review personnel file of Complainant. 9. Review personnel file of Accused. Basic form © James R. McDade (09-21-05) 209-667-2300INVESTIGATOR’S FINDINGSAlleged Event 1. ____________________________________________________________________Date of event: ________________________________Conclusion: Occurred Did not occur Probably occurred Probably did not occur Inconclusive Describe evidence and witness statements that support the conclusion: _________________________ ____________________________________________________________________________________ ___________________________________________________________________________________Alleged Event 2. ____________________________________________________________________Date of event: ________________________________Conclusion: Occurred Did not occur Probably occurred Probably did not occur Inconclusive Describe evidence and witness statements that support the conclusion: _________________________ ____________________________________________________________________________________ ___________________________________________________________________________________Alleged Event 3. ____________________________________________________________________Date of event: ________________________________Conclusion: Occurred Did not occur Probably occurred Probably did not occur Inconclusive Describe evidence and witness statements that support the conclusion: _________________________ ____________________________________________________________________________________ ___________________________________________________________________________________Conclusion of Investigation____________________________________________________________________________________ ____________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________ Date: _____________________________Signature of Coordinating Investigator Basic form © James R. McDade (09-21-05) 209-667-2300INTERVIEW NOTES (Copy as many blank forms as are needed)Witness Name: ________________________________ Date of Interview: _______________________Location of Interview: ____________________________ Name of Interviewers: ___________________ Statement of confidentiality given to witness.Describe what happened and when: _________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________If applicable, does the witness know why the incident occurred? Describe: ____________________________________________________________________________________________________________Did the witness notice any injuries or damages resulting from the incident? Describe: ___________________________________________________________________________________________________ Witness Verification I affirm under penalty of perjury under the laws of the State of California that the above information is true and accurate to the best of my knowledge._______________________________________ Date: __________________________Witness Signature

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