Workplace Violence Incident Report

Workplace Violence Incident Report

To report a workplace violence incident, please provide the following information:
Report date and time:

MonthDayYear
Date
Hour MinutesAM/PM Option
Date and time when incident occurred:

MonthDayYear
Date
Hour MinutesAM/PM Option
What type of workplace violence incident?

Type 1 - person unaffiliated with SCSOSType 2 - Parent,student, employee of a district but not SCSOS, individual otherwise affiliatedwith SCSOS but not an employee of SCSOSType 3 - Employee of SCSOSType 4 - Individual in a relationship with, or related to an employee of SCSOS
Incident Location (Please provide specific details):
Individuals Involved (If known):
Description of incident
Conditions that may have contributed to incident (i.e., unlocked doors, after hours, no oversite at points of entry, etc.):
Names of witnesses
Was law enforcement called?

YesNo
Was your supervisor notified?

YesNo
Additional Comments/Concerns
I certify that the above information is true and correct.
Should be Empty: