Bill & Wendy Adams Disputes Limited

Impact Statement

Sometimes it is uncomfortable to confront another employee regarding what you consider to be violations of policy, acts of discrimination, or other actions that impact your ability to do your job and be a productive employee.
_____________________________________ (name of business)
would like to allow employees the opportunity to submit a written statement to the Human Resources Department that outlines how this situation has impacted your ability to do your job effectively. The purpose is to allow the person who committed the action to see the result that it has had on you, other employees and the business. This information may be used in a subsequent investigation. You may request an official discussion with the person involved in the incident. You may request any representative of your choosing or an appointed employee from the Human Resources Department to meet with you and the other employee. Please complete all parts of this form that apply to your situation. Add pages if needed.

I. Employees Involved
Employee Completing Form _____________________________________
Department __________________________________________________
Name of Employee(s) involved ____________________________________
____________________________________________________________
Reporting Relationship _________________________________________
Documentation that supports your concerns:

_____Emails
_____Telephone messages
_____Observed by other employees
_____Time Logs
_____Letters
_____ Reports
_____ Other
_____ None or I do not wish to disclose at this time.

Names of Employees or any others who observed the incident.
________________________________________________________________

________________________________________________________________

If observers are Employees, reporting relationship to person filing this statement.

________________________________________________________________

II. Incident Details
A. Describe the Incident and how you believe you were wronged.
________________________________________________________________

________________________________________________________________

B. Action you took as a result of the incident: Attempts to resolve your concerns.
Example: I brought it to the person’s attention verbally, brought it to the attention of my supervisor on ____date, wrote them an email asking for clarification, asked my supervisor for advice, contacted Human Resources. If no action was taken, why?
________________________________________________________________

________________________________________________________________

C. What was the response to your action from the other person, attempt to resolve, if any?
________________________________________________________________

________________________________________________________________

D. Was there any disciplinary action toward you or the other employee/employees as a result of the incident?
________________________________________________________________

________________________________________________________________

III. Personal effect and Business impact

A. Describe any personal effect of the incident. What you think, feel or believe as a result of your experience (Please add additional sheets, as necessary.)

________________________________________________________________

________________________________________________________________
B. Please describe the impact that this incident has had on the business: Example: Decreased productivity, days missed from work, decrease in team morale.
_____________________________________________________________________________
C. Describe any response needed from the organization as a result of the incident Example: An investigation, an advisory opinion from Human Resources, etc.

________________________________________________________________

_______________________________________________________________

________________________________________________________________

________________________________________________________________
IV. Changes you request

Please describe an appropriate remedy you would be consider acceptable that would be feasible or changes you would like to see as a result of this incident and any additional information you would like the Human Resources Department to consider.

Face to Face conversation with the other person and internal Managerial Mediator
A Meeting with Human Resources Conflict Response Team

Peer Review Panel

Apology from the other person
Recognition from the organization that I was wronged

________________________________________________________________________________

V. Injuries or Safety Violations

A. Were there any safety violations related to the incident?
B. If yes, describe.
________________________________________________________________________________
________________________________________________________________________________

C. Did you have any physical injuries as a result of this incident? (Check one) Yes No

D. If yes, describe the physical injuries and any medical treatment received. ________________________________________________________________________________

________________________________________________________________________________

VI. Economic Impact

A. Financial Loss

1. Property Loss. List the property lost as a result of this incident. This is property that has not been and is not expected to be recovered. (Attach any relevant receipts.)

________________________________________________________________________________

Total $ _______________

2. Property Damage. (List property damage as a result of this incident and attach estimates/bills for repair.)

Item Make Model Cost

_________________________________________________________________________

Total $ _______________

3. Medical/Hospital Costs, to include current or future costs

(Attach copies of bills.) Total $________________

4. Other Economic Losses/Costs — both current and future

(Lost wages and/or income — please specify type of loss) Total $________________

Subtotal A: (Property Loss + Property Damage + Medical/Hospital + Other) = Total $________________

B. Reimbursement Received

1. Property Insurance (Attach name and address of insurance company) _____________________

2. Hospital/Medical Insurance _ _____________________

3. Restitution Received _____________________

4. Other Reimbursement(s) _____________________

Subtotal B (Sum of Reimbursements) = $ ____________________

C. Economic Loss Not Reimbursed $ ____________________

(Subtotal A Minus Subtotal B)

Signature of Person Completing Form

_______________________________

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