PCI Workplace Violence Incident Report Form

Workplace Violence Incident Report Form
FACILITY/EMPLOYER ADDRESS
VICTIMS NAME

First NameLast Name
MALE/FEMALE
JOB TITLE
YEARS IN CURRENT JOB
HOME ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE
Please enter a valid phone number.Format: (000) 000-0000.
WORK PHONE
Please enter a valid phone number.Format: (000) 000-0000.
EMPLOYER NAME
JOB TYPE
SOCIAL SECURITY NUMBER
INCIDENT DATE

MonthDayYear
Date
INCIDENT TIME

Hour Minutes

AM/PM Option
SPECIFIC LOCATION WITHIN THE FACILITY, LOT, YARD, PARK, OR ROUTES
WORK LOCATION IF DIFFERENT THAN YOUR REGULAR WORKSITE/ROUTE
WORKPLACE VIOLENCE TYPE (INDICATE WHICH TYPE(S))
ASSAILANT/PERPERTRATOR (CHECK ONE)

Other
NATURE OF THE INCIDENT:
WERE YOU INJURED
IF YES, PLEASE SPECIFY YOUR INJURIES AND WHERE YOU RECEIVED TREATMENT
DID SECURITY RESPOND TO THE INCIDENT
HOW LONG DID IT TAKE SECURITY TO RESPOND
DID LAW ENFORCEMENT RESPOND TO THE INCIDENT
WHICH LAW INFORCEMENT AGENCY
POLICE REPORT FILED
IF SO, REPORT NUMBER
WAS YOUR SUPERVISOR NOTIFIED?
SUPERVISOR'S NAME
WAS THE LOCAL UNION REP NOTIFIED?
WHO SHOULD BE NOTIFIED?
WHAT ACTION WAS TAKEN BY EMPLOYER IN RESPONSE (SPECIFY)
ASSAILANT/PERPETRATOR NAME AND ADDRESS IF KNOWN:

First NameLast Name
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PLEASE BRIEFLY DESCRIBE THE INCIDENT:
INCIDENT DISPOSITION

Other
DID THE INCIDENT INVOLVE A WEAPON?
SPECIFY
DID YOU LOSE ANY WORK DAYS?
SPECIFY
WERE YOU SINGLED OUT OR WAS THE VIOLENCE DIRECTED AT MORE THAN ONE INDIVIDUAL?
WERE YOU ALONE WHEN THE INCIDENT OCCURRED?
DID YOU HAVE ANY REASON TO BELIEVE THAT AN INCIDENT MIGHT OCCUR?
WHAT MADE YOU BELIEVE THE INCIDENT MIGHT OCCUR
HAS THIS TYPE OR SIMILAR INCIDENT(S) HAPPENED TO YOU OR YOUR CO-WORKERS?
SPECIFY
HAVE YOU HAD ANY COUNSELING OR SUPPORT SERVICES SINCE THE INCIDENT?
SPECIFY
WHAT DO YOU FEEL CAN BE DONE IN THE FUTURE TO AVOID SUCH AN INCIDENT?
WAS THE ASSAILANT INVOLVED IN PREVIOUS INCIDENTS AT YOUR WORKSITE?
THERE ARE MEASURES TO PREVENT SIMILAR INCIDENTS:
SPECIFY
HAS CORRECTIVE ACTION BEEN TAKEN?
SPECIFY
COMMENTS
Should be Empty: