Workplace Violence Incident Report

Name of person reporting the incident*

Enter your name (or write "Anonymous" if you wish to remain anonymous)

Date & Time Of Incident*

Name of the person the incident was reported to*

Location of incident*

Was another companies representative contacted?*

Yes

Name of representative contacted

What type of workplace violence occurred?*

Type I violence - committed by a person who has no legitimate business at the worksite (e.g., violent acts by anyone who enters the workplace or approaches workers with intent to commit a crime).

Type II violence - directed at employees by customers, clients, patients, students, inmates, or visitors.

Type III violence - against an employee by a present or former employee, supervisor, or manager.

Type IV violence - committed in the workplace by a person who does not work there but has or is known to have had a personal relationship with an employee.

Description of the event*

Who committed the violence?*

e.g., client or customer, family or friend of a client or customer, stranger with criminal intent, coworker, supervisor or manager, someone's partner or spouse, parent or relative, or another perpetrator

What were the circumstances at the time of the incident?*

e.g., completing usual job duties, working in poorly lit areas, rushed, low staffing level, isolated or alone, unable to get help, community setting, unfamiliar or new location

Where did the incident occur?*

(i.e., at the workplace, parking lot or other area outside the workplace, or other area)

What nature of violence occurred?*

Physical attack without a weapon, including but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting. Attack with a weapon or object, including but not limited to, a firearm, knife, or other object. Threat of physical force or threat of the use of a weapon or other object. Sexual assault or threat, including but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact. Animal attack.

What was the outcome of the incident, including, but not limited to:*

Whether security or law enforcement was contacted and their response

What actions were taken to protect employees from a continuing threat or from any other hazards identified as a result of the incident?

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