Workplace Violence Incident Reporting Form

Atech Logistics & Distribution Workplace Violence Incident Reporting Form
Following the event of a workplace violence incident, to help the company investigate and respond appropriately, please complete this form describing the circumstances of the incident. Upon submission this form will be sent to the appropriate supervisor, HR personnel or other individual(s) designated to receive such information under the company’s Workplace Violence Prevention Plan. Please be as specific as possible in order to help the company gain an accurate understanding of the incident in order to respond appropriately as part of its ongoing efforts to correct and prevent workplace violence hazards and maintain a safe working environment.
Section 1: Information About the Individual Completing Form
Name*
Job Title
Date Completed*

MonthDayYear
Date
Section 2: Information About the Incident
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
Location of Incident*
Classify the nature of the location (e.g., workplace, parking lot, area outside of workplace or other area)*
Classify, if possible, the type of person that committed the violence (e.g., customer/client or their family member, coworker, spouse, parent, or other family member or stranger with criminal intent)
Please list any additional witnesses or individuals involved in the incident
Describe the incident in detail. If possible, try to recall and describe the circumstances surrounding the incident, including, but not limited to, whether the employee that experienced the violence was completing usual job duties, working in poorly lit areas, rushed in their duties, working during a low staffing level, isolated or alone, unable to get help or assistance, working in a community setting, or working in a new or unfamiliar location.
Should be Empty:

Atech Logistics & Distribution Workplace Violence Incident Reporting Form

Section 1: Information About the Individual Completing Form

Section 2: Information About the Incident