Workplace Violence Employee Report

Company Name *

Date of Report *

Employee Name *

First

Last

Email Address *

Please enter the email address where you would like to receive a copy of this incident report.

Date and Approximate Time of Incident *

Date

Time

Location of Incident *

Types of Workplace Violence

Workplace violence means any act of violence or threat of violence that occurs at the work site. The term ‘workplace violence’ shall not include lawful acts of self-defense or defense of others. Workplace violence includes the following:

- The threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury;

- An incident involving the threat or use of a firearm or other dangerous weapon, including the use of common objects as weapons, regardless of whether the employee sustains an injury;

Select one of the following workplace violence categories that best describes the type of incident. *

Please describe the type of incident. *

You selected Type 5: Other for the type of incident in the previous question. Please describe this "other" type of incident or select a different type above.

Select who the workplace violence was committed by: *

Please describe who the workplace violence was committed by. *

You selected Other for who the workplace violence was committed by in the previous question. Please describe this "other" type of person or select one above.

Select which of the following best describes the type(s) of incident. *

Please describe the type of workplace violence incident. *

You selected Other for the type of incident in the previous question. Please describe this "other" type of incident or select one above.

Name of Person Committing Violent Act *

First

Last

Name of Witness *

First

Last

Circumstances at the time of the incident. *

Include what was happening just before and at the time of the incident, job task, working in poorly lit areas, rushed, working during a low staffing level, working alone, unable to get help, working in a community setting, or working in an unfamiliar location etc..

Did you receive injuries? *

Please explain types of injuries you sustained *

Was anyone else injured? *

Name of Others Injured *

First

Last

Were emergency medical responders other than law enforcement contacted, such as Fire Department, Paramedics, On-site First-aid personnel? *

Description of Violent Incident *

Include as much detail as possible for each phase of the incident.

Would you like to request counseling? *

Would you like to request medical care? *

A strict non-retaliation policy is in place, and any instances of retaliation are dealt with swiftly and decisively. We will make every reasonable effort to maintain confidentiality of the individual reporting an incident of workplace violence. Only authorized personnel will have access to a submitted incident report. Those who may review the incident report may include your Management, Authorized Investigators, Human Resources, Designated Safety Manager, and Legal Advisors.

If you've provided an email address, you'll receive an email containing this completed incident report once it's submitted.

Signature of person this incident report was completed by: *

Clear Signature

Log ID Number

For Office Use Only (if known)