SRSRC Report of Workplace Violence or Threat of Violence
If this concerns an imminent emergency, contact the authorities. This form may be used to report incidents, threats, hazards, and/or concerns of workplace violence. Please note that although SRSRC will make efforts to maintain confidentiality, confidentiality cannot be guaranteed when information disclosed is deemed necessary to disseminate for safety purposes.
What type of report are you making?
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Anonymous Report of a hazard and/or concern of workplace violence.
Report of a hazard and/or concern of workplace violence.
Anonymous Report of an incident or threat of workplace violence.
Report of a an incident or threat of workplace violence.
Your Name - Optional
First Name
Last Name
Your Name
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First Name
Last Name
Job Title
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Description of hazard and/or concern of workplace violence.
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Date of Incident
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-
Month
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Day
Year
Date
Time of Incident
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Hour Minutes
AM
PM
AM/PM Option
Location
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Aviary
Trails
Children's Center
Other
Specific Location of Incident
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Where at the worksite did this occur?
Type of Workplace Violence
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“Type 1 violence,” which means workplace violence committed by a person who has no legitimate business at the worksite, and includes violent acts by anyone who enters the workplace or approaches workers with the intent to commit a crime.
“Type 2 violence,” which means workplace violence directed at employees by customers, clients, patients, students, inmates, or visitors.
“Type 3 violence,” which means workplace violence against an employee by a present or former employee, supervisor, or manager.
“Type 4 violence,” which means workplace violence committed in the workplace by a person who does not work there, but has or is known to have had a personal relationship with an employee.
N/A - act of self-defense or defense of others
Other
Type of Incident
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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 of 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
Individual Committing the Violence
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Include whether the perpetrator was a client or customer, family or friend of a client or customer, stranger with criminal intent, coworker, supervisor or manager, partner or spouse, parent or relative, or other perpetrator.
Detailed description of Incident, Threat, Hazard, and/or Concern
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Include all relevant details. Include who committed or threatened workplace violence, and the context in which it occurred. Include whether or not the authorities were contacted.
Circumstances at the Time of the Incident
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Including, but not limited to, whether the employee was completing usual job duties, working in poorly lit areas, rushed, working during a low staffing level, isolated or alone, unable to get help or assistance, working in a community setting, or working in an unfamiliar or new location.
Was law enforcement or security contacted?
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Yes
No
Unknown
Description of the Response
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Describe the response taken by security and/or law enforcement.
Were emergency medical responders other than law enforcement contacted, such as a Fire Department, Paramedics, or On-site First-aid certified personnel?
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Yes
No
Unknown
Description of the Response
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Describe the response taken by emergency medical responders other than law enforcement contacted, such as a Fire Department, Paramedics, or On-site First-aid certified personnel.
If you notified a supervisor/head staff member, who was notified?
Tal O'Farrell - General Manager
Amy Alexander - Assistant General Manager
Tish Alexander - Front Desk Coordinator
Monique Berumen - AAF, MRP, and Camp Director
Shauna Dok - Fitness Director
Wendy Drobnicki - Accounts Specialist
Robin Harris - Tennis Director
Keela Lindsay - Childrens Center Director
Cristian Moreno - Maintenance Supervisor
Kristin Neth - Aquatics Director
Jerry O'Mara - Weekend Manager
Monica Oates - Camp Director
Shana Smith - Special Event Coordinator
Heidi Verner - Group Fitness Director
N/A - supervisor/head staff not notified
Submit
Should be Empty: