Workplace Violence Incident Report
Workplace Violence Incident Report
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
Name of Victim
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
Yes Union/Local
No
SECTION III
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
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
No
Yes
Was medical treatment provided? Victim Yes No If yes, describe: Assailant Yes If yes, describe: No
No
Yes
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
SECTION VIII
SECTION IX
SECTION X
What happened to assailant? (Final disposition of incident) Describe specifically (Arrested, Discipline, Transferred, etc.)
SECTION XI
Date
Phone Number
Describe Incident in Detail. Include what happened, where, who was involved, other witnesses, what you heard, saw, etc.
Date Date