Workplace Violence Incident Report

Name(Required)

Name/Title/Contact Information of Person Completing Form(Required)

Date/Time(Required)

Location/Department(Required)

Violence Commited By:(Required)

The perpetrator will be classified as: (1) client or customer; (2) family or friend of a client or customer; (3) stranger with criminal intent; (4) co-worker, supervisor or manager of victim, (5) partner or spouse, parent or relative of victim, or (6) other perpetrator.

Incident Description(Required)

Type of Incident (Check all that apply)

Physical attack without a weapon (e.g. biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting

Attack with a weapon (e.g. gun, knife, other object)

Threat of physical force or use of a weapon or other object

Sexual assault or threat (rape or attempted rape, physical display, or unwanted verbal or physical sexual contact)

Verbal Harassment

Animal Attack

Other

If other is selected please specify here

Incident Location Specifics: (Check all that apply)

Other

If other is selected please specify here

Incident Specifics: (Check all that apply)

Victim Performing Usual Job Duties

Poor Lighting

Rushed

Working During Low Staffing Level

High Crime Area

Isolated/Alone

Unable to Get Help/Assistance

Working in a Community Setting

Working in an Unfamiliar/New Location

Consequence Specific: (Check all that apply)

Medical Treatment Provided

Assistance Provided to Conclude Incident (detail in Incident Description)

Security Contacted

Law Enforcement Contacted

Lost Time of Work Hours

Actions Requested to Protect from Continuing Threat (if any)

Action Requested

Please provide details of requested actions