Workplace Violence Employer Report

Log ID Number

Company Name *

Date of Report *

Name of Management/Supervisor completing this report: *

First

Last

Email Address *

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

Date and Approximate Time of Incident *

Date

Time

Location of Incident *

This log must be used for every workplace violence incident that occurs in our workplace. At a minimum, it will include the information required by LC section 6401.9(d) attach additional information as needed.

The information that is recorded will be based on:

- Information provided by the employees who experienced the incident of violence.

- Witness statements.

- All other investigation findings.

All information that personally identifies the individual(s) involve will be omitted from this log, such as names, addresses, phone numbers, and social security numbers.

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.

Description of Violent Incident *

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

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..

Consequences of the incident. *

Include what the consequences of the incident were. This may include security/law enforcement response, or actions taken to protect employees from threat.

Were there injuries? *

Please explain the types of injury and to whom. *

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

Please explain the type of medical responders who were contacted. *

Does the severity of the injuries require reporting to Cal/OSHA? *

Please document the report to Cal/OSHA.

Name of the Cal/OSHA Representative *

First

Last

OSHA Office Location *

Representative Name/Other: *

Date and Approximate Time of Report to Cal/OSHA *

Date

Time

This violence incident log was completed by:

Name *

First

Last

Title *

Date Incident Log Completed *

Signature of person this incident report was completed by: *

Clear Signature