SRSRC Report of Workplace Violence or Threat of Violence

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?
Your Name - Optional

First NameLast Name
Your Name

First NameLast Name
Job Title
Description of hazard and/or concern of workplace violence.
Date of Incident

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
Location

Other
Specific Location of Incident
Where at the worksite did this occur?
Type of Workplace Violence

Other
Type of Incident

Other
Individual Committing the Violence
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
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
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?
Description of the Response
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?
Description of the Response
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?
Should be Empty: