Required fields are marked with asterisks (*)

R-Zone Incident Report

The Municipality of Kincardine will exercise no tolerance for any form of violence, vandalism, or inappropriate behaviour in its programs, facilities, or properties. The R-Zone Policy webpage provides more detail, and the form below may be used to report incidents which violate the R-Zone.

Individual Reporting Details

Name of Person Reporting:

Department (if applicable):

Position (if applicable):

Phone:

E-mail Address

Date incident was reported:

Incident Information

Date of the incident:

Please provide the time the incident occured:

Location of Incident:

Incident Information:

Participants Involved

Complainant Name:

Address:

Postal Code:

Phone:

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Respondent Name:

Address:

Postal Code:

Phone:

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Type of Incident

Please check all that apply:

Harassment

Physical Assault/Harm

Possession of Weapon(s)

Theft of Property

Threats

Use of Drugs/Alcohol

Vandalism

Verbal Assault

Other

Detailed description of incident

Other relevant information

Who was made aware of the incident?

Name:

Address:

Postal Code:

Phone:

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If another individual was made aware of the incident, how were they informed?

In-person

E-mail

Phone

Other

Please identify any witnesses to the incident

Name:

Address:

Postal Code:

Phone:

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For Office Use Only

Action Taken (check all that apply)

Verbal Warning

Letter of Warning

Letter of Trespass

Appeal

Yes

File Closed

Yes

Staff Name:

Staff Position:

Personal information on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, C.25 and will be used for the purpose of aggregate statistical reporting, and allocation of staff and resources. This information will also be used for the promotion of programs or activities so that we can provide good customer service.

Questions about the collection of the personal information may be addressed to the Clerk of the Municipality of Kincardine by phone at 519-396-3468, by e-mailing, or by mailing:

Municipality of Kincardine
Attention: Clerk
1475 Concession 5
Kincardine, Ontario
N2Z 2X6