Associates – Confidential:          
 
Use this form to document an issue of a serious or personal nature regarding another associate.  Examples of when this form should be used include: to report workplace harassment of any kind; to report unethical or unprofessional behavior by an associate; to report serious violations of Life EMS policies.  Forms submitted are only reviewed by the Executive Vice President and Human Resources and are strictly confidential
 
 

Incident Title *
Life EMS Operation
Run Numer (if applicable)
Date of Incident
Time of Incident
Your Name
Your Phone Number
Names of Other Associates Involved
Description of Incident