Workplace Violence Incident Report

Workplace Violence Incident Report
Incident Information
Location/Site:*
Staff Reporting:*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Incident Date & Time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Emergency Services Activated?*

911CARCATFire DepartmentPolice DepartmentNoneOther
Type of Incident: (select more than one, if necessary)*

Belligerent speech or excessive swearingDefacing company property or causing physical damage to facilitiesEmergency Lockdown or ThreatHarassment or BullyingRefusal to follow company policies and proceduresSabotage or threats of sabotageThreatening, physically aggressive, or violent behaviorOther
Select Critical Level:*
Was this a site wide event?
Member/Staff Information
Were members or minor clients involved?

YesNoUnknown minor(s)
Member 1 Information

First NameLast Name
Member 1 Age
Member 2 Information

First NameLast Name
Member 2 Age
Member 3 Information

First NameLast Name
Member 3 Age
Member 4 Information

First NameLast Name
Member 4 Age
Does the member have an intellectual or developmental disability?

YesNo
Were any staff/adult(s) involved?

YesNoUnknown stranger(s)
Staff/Adult 1 Information

First NameLast Name
Adult 1 Type:
Staff/Adult 2 Information

First NameLast Name
Adult 2 Type:
Staff/Adult 3 Information

First NameLast Name
Adult 3 Type:
Staff/Adult 4 Information

First NameLast Name
Adult 4 Type:
Other Witnesses:
Incident Details
Location of Where Incident Occurred:*
Describe the Incident (be specific, facts only):*
Describe Injury/Symptoms (if any):
Required if injury or illness occurred.
If this incident involved a staff injury, were they provided WC paperwork?
Was First Aid Given?*

YesNo
First Aid Consisted Of:
Required if First Aid was given. Please indicate if a Head Injury Form was sent home with parent.
Parent/Guardian Information
Was Parent/Guardian of the Member Notified?

YesNoSite Wide Event - All NotifiedN/A
Parent/Guardian Name

First NameLast Name
Parent/Guardian Notification Date & Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Were other Parents or Guardians Notified?

YesNoN/A
Parent/Guardian 2 Name

First NameLast Name
2 - Notification Date

MonthDayYear
Date
Parent/Guardian 3 Name

First NameLast Name
3 - Notification Date

MonthDayYear
Date
Parent/Guardian 4 Name

First NameLast Name
4 - Notification Date

MonthDayYear
Date
Parent/Guardian 5 Name

First NameLast Name
5 - Notification Date

MonthDayYear
Date
Notes from Parent/Guardian:
Optional, but encouraged.
Incident Status & Follow Up
Incident Status:*

Pending: Follow Up NeededFully Resolved: Incident Closed
What follow up is needed?
The following have been notified of the incident (Check all that apply):*

No additional notification necessaryDirect Supervisor or ManagerArea or Site DirectorExecutive Team MemberCHS Team
Upload any pictures or relevant documents:

Optional - multiple files can be uploaded.
Cancelof
After Submission Follow Up

Insert any updates of the incident here - include date & initials!
Incident Updates:
Should be Empty:

Workplace Violence Incident Report

Incident Information

Member/Staff Information

Incident Details

Parent/Guardian Information

Incident Status & Follow Up

After Submission Follow Up