GCC/IBT

LOCAL 140-N
Confidential Incident Report Form
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(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
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Person Submitting Report: ____________________________ Date Received: _________

(FOR UNION USE ONLY)