Log: Violence Incident Log PCI

This log must be used for every workplace violence incident that occurs in our workplace. At a minimum, it will include the information required by LC section 6401.9(d).

The information that is recorded will be based on:
·        Information provided by the employees who experienced the incident of violence.
·        Witness statements.
·        All other investigation findings.

All information that personally identifies the individual(s) involved will be omitted from this log, such as:

· Names

· Addresses – physical and electronic

· Telephone numbers

· Social security number

Date incident occurred

Date

Approximate time incident occurred

Hour Minutes

AM/PM Option

List the Location # and Location Name where this incident occurred

Workplace violence type (Indicate which type(s)

Check which of the following describes the nature of the incident.

Explain: [Provide a detailed description of the incident and any additional information on the violence incident type and what it included. Continue on separate sheet of paper if necessary.]

Workplace violence committed by:

Circumstances at the time of the incident: write/type what was happening 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.

Where the incident occurred: [ Such as in the workplace, parking lot or other please be specific.]

Describe follow-up on actions taken

Security responded in:

Was law enforcement contacted?

Describe what happened when security/law enforcement responded:

Was the incident resolved?

Did the perpetrator run away from the scene?

Did security or law enforcement remove the perpetrator from the premises?

Were there any injuries?

Were emergency medical responders other than law enforcement contacted, such as Fire Department, Paramedics, On-site First-aid certified personnel?

Please describe the nature of the injuries and other explanation:

This violent incident log was completed by:

First NameLast Name

Job title:

Signature

Date

MANAGER EMAIL

example@example.com

Please save this when complete and then click SUBMIT.