USA Pears Incident Investigation Form

Incident Investigation Form

Tell us what happened in the form below.
Your Name (Optional)
Your contact information: phone, email, etc. (Optional)
Your Company Name (Optional)
Date of Incident

MonthDayYear
Is the incident ongoing?

YesNo
If yes, how long have you been aware, and how long has this been occurring?
Name of individual(s) involved in the incident
Where did the incident occur?
Describe, in detail, what happened:*
Who else may have seen or heard the incident?
Have you discussed the incident with anyone else? If so, whom?
Are there any notes, physical evidence or other documentation regarding the incidents?
Upload any documentation or pertaining files here:

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Is there anyone else who may have relevant information?

YesNo
If yes, please list their name and contact information here:
What other information is relevant to this situation?
Thank you for taking the time to send us this information. We understand that what you have provided may be sensitive and critical information. The matter will be investigated, and no conclusions will be made until all facts are gathered and considered.

Pear Bureau Northwest prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, sex, religion, political beliefs, or disability. Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact the Pear Bureau at (503) 652-9720.

To file a complaint of discrimination, write the USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue SW, Stop 9410, Washington, DC, 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).
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