Workplace Violence Incident Report
Section 1: Information About the Individual Completing Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Section 2: Information About the Incident
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Company
Please Select
Confirmation Email
example@example.com
Name of Victim (if different than individual reporting)
First Name
Last Name
Name of Perpetrator (Description if name unknown)
Relationship between Victim and Perpetrator (Husband/Wife, Father/Son, coworkers, community member/staff member, etc.)
Exact location of incident
Type of Incident
Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting
Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object
Threat of physical force or threat or the use of a weapon or other object
Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.
Animal attack
Other
Detailed Description of the incident
Witness 1 (include a way to contact them if you have it)
Witness 2 (include a way to contact them if you have it)
Supplementary Documentation/Pictures/School or Clinic Incident Report, etc.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: