Workplace Violence Incident Report
To report a workplace violence incident, please provide the following information:
Report date and time:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and time when incident occurred:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What type of workplace violence incident?
Type 1 - person unaffiliated with SCSOS
Type 2 - Parent,student, employee of a district but not SCSOS, individual otherwise affiliatedwith SCSOS but not an employee of SCSOS
Type 3 - Employee of SCSOS
Type 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?
Yes
No
Was your supervisor notified?
Yes
No
Additional Comments/Concerns
*
I certify that the above information is true and correct.
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Should be Empty: