AT Program Disciplinary Incident Report Form

Cumberland University Athletic Training Program Disciplinary Incident Report Athletic Training Handbook 39 Name: ________________________________________ Clinical Rotation: _______________________________ Incident Date: ___________________________________Incident Location: _______________________________ Witnesses: ____________________________________________________________________________________ Reason for Report: □ Insubordination □ Unprofessional Behavior □ Breach of Duty □ Unexcused Absences □ Chronic Tardiness □ Theft/Vandalism □ Sexual Harassment □ Falsifying Hours □ Academic Dishonesty □ Drug/Alcohol Abuse □ Conduct Unbecoming an Athletic Trainer □ Dress Code Violation □ Other ____________________ Incident Description: ____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Student Athletic Trainer Signature __________________________________________ Date _________________ Staff Athletic Trainer Signature ____________________________________________ Date __________________ I, the undersigned, understand that my signature below IS NOT an admission of guilt, but rath acknowledgment of the report. Each deficiency will be reviewed on a case-by-case basis. I al refusal to sign this document by the aforementioned athletic trainer will be considered an adm subsequent disciplinary action will be taken as outlined in the Cumberland University’s Ath Program’s Discipline Action Policy. Reviewed by: __________________________________________ Comments/Remarks: