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Workplace Violence Incident Report Form

This document reports a workplace violence incident. It contains forms for reporting details of an incident such as dates, locations, individuals involved, the nature of the incident, injuries, and responses. Witness statements and follow ups are to be attached upon completion of the investigation.

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amrpoiu2016
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245 views3 pages

Workplace Violence Incident Report Form

This document reports a workplace violence incident. It contains forms for reporting details of an incident such as dates, locations, individuals involved, the nature of the incident, injuries, and responses. Witness statements and follow ups are to be attached upon completion of the investigation.

Uploaded by

amrpoiu2016
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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WORKPLACE VIOLENCE INCIDENT REPORT

To be completed by the individual investigating the incident. Return completed form within 2 days following incident to
Human Resources. Attach witness statements to this form.

Report submitted by: Date:

General Description: Telephone:

Date of Incident: Time:

Address/Location of Incident:

Individuals involved in the incident (use additional sheet(s) if necessary)


Name: Name:

Victim or Assailant Victim or Assailant

Title: Title:

Division: Division:

Phone: Phone:

Immediate Supervisor: Immediate Supervisor:

Assailant Relationship to Employee


Co-worker Former Employee

Other (specify)

Possible Reason for Incident: (If known, check all that apply)
Conflict with co-worker(s)/former co-worker Receiving corrective action

Conflict with management Other (specify)


Nature of Incident
Stalking

Engaging in actions intended to frighten, coerce, or induce duress

Destruction of Property

Phyisical Assault - Hitting, fighting, pushing, or shoving

Armed Assault - Use of object as weapon (specify)

Armed Assault - Use of weapon such as gun, knife, etc. (specify)

Verbal Harassment

Sexual Harassment

Other (specify)

How was the incident communicated? (Check one or more)


Communicated directly to victim Verbal Mail Note Email

Communicated to another person Verbal Mail Note Email

Other (specify)

Victim Injury (Check all that apply)


Physical injury

Physical Injury - Medical care required

Initial Response or Follow up Activity: (Check all that apply)


Situation defused Occupational Medicine notified

Security called Law Enforcement notified


If Yes, Name of Agency and Report Number:

Other (specify) Employee Assistance Program referral


Describe Incident in Detail
Include what happened, where, who was involved, what you heard, saw, etc.

List Names of Other Witnesses

Signature Date

Person Receiving Witness Statement Date

Routing
Yes No Name Signature Date
Group Manager
Associate Director/Department Head
Security Manager
EAP

Upon completion of investigation, attach a findings/follow-up document to this form.

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