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Workplace Violence Incident Report

This document contains forms for reporting workplace violence incidents at Rutgers University. The forms collect information about the date, time, location of incident, those involved including the victim, assailant, and any witnesses. Details about the specific incident are to be described, including what happened, any injuries or property damage, whether authorities were contacted, and follow up actions taken. Witness statements may also be attached. The forms are to be completed as soon as reasonably possible by victims and witnesses of workplace violence incidents at Rutgers University.
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0% found this document useful (0 votes)
438 views4 pages

Workplace Violence Incident Report

This document contains forms for reporting workplace violence incidents at Rutgers University. The forms collect information about the date, time, location of incident, those involved including the victim, assailant, and any witnesses. Details about the specific incident are to be described, including what happened, any injuries or property damage, whether authorities were contacted, and follow up actions taken. Witness statements may also be attached. The forms are to be completed as soon as reasonably possible by victims and witnesses of workplace violence incidents at Rutgers University.
Copyright
© Attribution Non-Commercial (BY-NC)
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 Form

As soon as is reasonably possible, victims and/or witnesses of workplace violence should document incidents by completing and filing this report form. NOTE: Not all questions may be applicable to each particular circumstance reported.
SECTION I

Date of Incident

Day of Week

Time

A.M. or

P.M.

Date of Report

Location of Incident (map or sketch on reverse side)


SECTION II

Was there property damage? Briefly list

Name of Victim

Victims Phone #s Home Work Cell

Victims Gender Male

Home Address

Female

Campus Location Victims email address Victim Description Staff Faculty Department Student/Parent Client/Customer
(Explain other)

If victim is staff or faculty: Job title Visitor Other Division Chair/Supervisors Name Was supervisor notified No Date and Time Yes

Is victim a unionized employee?

Yes Union/Local

No

SECTION III

Name of Assailant Home Address

Assailants Phone #s Home Work

Assailants Gender Male Female

Campus/Location Cell Assailants email address Relationship of Assailant to Victim Co-worker Spouse/Partner Client/Customer Other (Describe) Student/Parent Faculty Supervisor Stranger

Did incident include a weapon? If yes, describe the weapon How was it used?

No

Yes

University Human Resources 848-932-3020 FAX 732-932-0046 uhr.rutgers.edu

SECTION IV

Describe incident (CHECK ALL that apply and use the Workplace Violence Incident Report Victim/Witness Account Form to describe the incident in detail) Harassed by email or other written Scratched Vandalism (others property) communication Slapped Vandalism (employers property) Harassed verbally Hit with hand/fist/other body part Vandalism (own property) Threatened verbally Hit with object Animal Attack Threatened with a weapon Assaulted with weapon Arson Bitten Assaulted sexually Bomb threat Grabbed Shot (or attempted) Robbery Kicked Knifed (or attempted) Other (Describe) Pushed Stalked
SECTION V

Was victim or assailant injured? If yes, describe

No

Yes

Was medical treatment provided? Victim Yes No If yes, describe: Assailant Yes If yes, describe: No

Was injury report filed?

No

Yes

Date: Was victim referred to counseling? Yes No


SECTION VI

Was assailant referred to counseling? Yes No Crisis Response Team notified? Yes Date and time No Restraining order issued? No Was assailant arrested? No Police notified? Yes Date and Time No Date and Time Date and Time

Threat Management Team notified? Yes Date and Time No Responding Police Officer Name Badge #

Yes Yes

If yes, what were the charges? Municipality/Agency


SECTION VII

List of witnesses (attach witness reports)

SECTION VIII

Measures taken to prevent recurrence:

University Human Resources 848-932-3020 FAX 732-932-0046 uhr.rutgers.edu

SECTION IX

What remedy, if any, does the victim request?

SECTION X

What happened to assailant? (Final disposition of incident) Describe specifically (Arrested, Discipline, Transferred, etc.)

SECTION XI

Name of person completing this form

Address or Work Location

Date

Work phone number

Relationship to victim or assailant

University Human Resources 848-932-3020 FAX 732-932-0046 uhr.rutgers.edu

Workplace Violence Incident Report Victim/Witness Account Form


Note: Complete this Form if you are the victim of or witness to the alleged workplace violence Photocopy additional copies as needed
Date of Incident Name Victim Witness Address/City Location of witness Date of Report

Phone Number

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

List Names of Other Witnesses

Signature Person Receiving Witness Statement

Date Date

University Human Resources 848-932-3020 FAX 732-932-0046 uhr.rutgers.edu

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