Gcc Ibt Incident Report Form

GCC/IBT LOCAL 140-N Confidential Incident Report Form Page ___ of ___ (Please print legibly or type) Date of Incident: _____________________

Report Date: ________________

If applicable: Were you denied your “Weingarten Rights” – (the right to union representation): Yes or No _____________ Name(s) of Alleged Violator(s):

Witness(es):

Location of Incident: _________________________________________________________ Time: ____________ a.m./p.m. Details of Incident: (Please print legibly in black ink or type and be as specific as possible stating the facts. There is more space available on the back of this form or you may submit additional pages)

Check here if continued on back or if there are additional pages: _____________ (FOR UNION USE ONLY)

GCC/IBT Confidential Incident Report Form LOCAL 140-N (continued) Page ___ of ___

Person Submitting Report: ____________________________ Date Received: _________ (FOR UNION USE ONLY)