CODE OF CONDUCT INCIDENT REPORTING

Cary Institute takes all allegations of violations of its Code of Conduct for Events very seriously. Cary Institute will strive to keep the identity of the individual making the claim and the reported information as confidential as possible, consistent with the need to conduct an adequate review and to comply with applicable laws. Violators will be dealt with in accordance with the Code of Conduct.

Please fill out as many questions as possible to ensure a thorough investigation may be conducted and appropriate action is taken.

1. Are you a Cary Institute trustee, officer, employee, or volunteer? *

Yes No

2. Is the person about whom this report is being filed a Cary Institute trustee, officer, employee, or volunteer? *

Yes No

3. If the answer to Question 2 is “YES”, please CONTINUE to fill out this form.

Please note that you may be requested to complete a Cary Institute “Whistle Blower Complaint Form” A copy of Cary Institute’s Whistle Blower Policy can be downloaded from the HR Forms section of the Cary Intranet.

4. What is the name and dates of the meeting are you attending? *

5. Who is the meeting organizer or person in charge of running the meeting you are attending? *

6. Is the meeting located in-person at Cary Institute, virtually, or at an off-site location? If off-site, where? *

7. How were you involved in the incident? *

Directly (the behavior was directed towards you) Indirectly (you observed the behavior or was informed by another person)

8. What type of code of conduct violation or incident are you reporting? Check all that apply. *

Harassment, intimidation, threats, violence, or offensive/unwelcome behavior (including invasion of privacy) Disruptive and/or disrespectful behavior (including such behavior while under the influence of drugs or alcohol) Physical or verbal abuse Discrimination verbal, or nonverbal harassment or hostility against any person or group of people Abuse of power Sexual harassment or sexual assault Impersonating another individual or intentionally deceiving others by communicating under a false name Other

9. Did you or someone else ask the offending party to stop the violating behavior? *

No Yes

If yes, what was the outcome? *

10. Please describe the incident. Include as many details as possible (what happened, when did it take place, where did the incident occur). *

11. Please identify the person involved in the incident (name, affiliation), if known. *

12. What is your preferred resolution to this incident? *

13. Please provide your name and contact information (affiliation, e-mail address, cell phone number). With your permission, this will allow us to contact you if we need additional details.

Name

First Name Last Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

14. If needed, may we follow up with you? *

No Yes

15. Please share any additional details in the space below that you feel may assist an investigation of the incident.

16. FORM SUBMISSION

To submit your form electronically, click the “Submit” button below.

Please verify that you are human *