Anders Group Incident/Complaint Report Name of Involved Employee*Modality*Date/Time of Incident*Name of Person Reporting Complaint/Incident*Facility/Location*Was illness or injury involved? (Describe below)* Yes No Was this an Anders Group related issue? (Describe below)* Yes No Description of Incident/Complaint - include names of individuals involved, nature of the incident/complaint, if injury or illness give name of physician/hospital used, names & addresses of witnesses, and narrative of what occurred.*Final Anders Group Disposition - how you intend to handle to incident/complaint, any next steps required, or likely outcomes.*Is the Anders Group employee considered a DNU by the facility? Yes No Is the Anders Group employee considered a DNU by Anders Group? Yes No Recruiter Submitting Report*Date of Report*Please note incident, all communication, and follow ups of this incident in Bullhorn, and print all possible documentation to put in personnel file with this report.