Liaison Email
example@example.com
Workplace Violence Incident Reporting
Please take a moment to report a suspected workplace violence. Your information will remain confidential.
Personal Information
Name
*
First Name
Last Name
Employee ID Number
Optional for non-CTFF employees
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
School Name
*
Email
*
example@example.com
Liaison
*
Please Select
Adriana Pantoja
Andrea Barriga
Arianah Perez
Ashley Martinez
Cassandra Bautista
Christopher Gomez
Christopher Rosas
Cielo Corona
Cindy Rodriguez
Clarissa Garcia
Devon Sakata
Esmeralda Gordillo
Fatima Cardoso
Gabriela Maravilla
Ger Vue
Gloria Dominguez
Inez Barboza
Ivana Valdovinos
Jesel Morales
Jesus Aguiniga
Jesus Rodriguez
Jo Limon
Jose Ortiz
Katie Ballesteros
Lexie Rodgers
Liz Jaramillo
Lizeht Hernandez
Lizette Ramirez
Lucy Lee
Maria Chacon
Mariela Flores
Mariela Zamora
Marizabel Magallan
Martha Leon
Michael Torres
Orlanda Hernandez
Sade Turner
Sarah Cruz
Susana Mesa
Viviana Ramirez
Yain Velazco
Yajaira Anaya
Yvonne Carlos
Victor Leon
Incident Details
Incident Location
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Workplace Violence Type:
*
Type 1: 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: Workplace violence directed at employees by customers, clients, patients, students, inmates, or visitors.
Type 3: Workplace violence against an employee by a present or former employee, supervisor, or manager.
Type 4: 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.
Detailed Description Of The Incident:
*
What grade is the student in?
*
Was the perpetrator of violence a:
*
Customer or client (including students)
Family or friend of a customer or client
Stranger with criminal intent
Coworker
Supervisor or manager
Partner or spouse
Parent or other relative
Other
At the time of the incident, was the employee: (check all that apply)
*
Completing usual job duties
Working in poorly lit area(s)
Rushed
Working during a low staffing level
Isolated or alone
Unable to get help or assistance
Working in a community setting
Working in an unfamiliar or new location
Where did the incident occur?
*
Inside the workplace
In a parking lot or other area outside the workplace
Other
Did the incident involve any of the following? (check all that apply)
*
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
Were there any injuries?
*
Yes
No
Consequences of the incident:
*
Security or law enforcement was contacted
Emergency medical responders (other than law enforcement) who were contacted, such as fire department, paramedics, on-site first aid certified personnel, etc.
Actions taken to protect employees from a continuing threat or from any other hazards identified as a result of the incident.
Please list the agency contacted and their response:
*
Please provide additional information
*
Please upload any supporting documents provided to you.
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Workplace Violent Incident Investigation Report
Incident Description
*
Enter details, including all events that led up to the incident.
Please upload any supporting documents that you may have.
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Employees Involved
*
Enter First and Last Names of all employees Involved
Underlying Cause(S) Of The Incident:
*
Corrective Actions Taken:
*
Provide details, including potential solutions to the root cause(s), if applicable.
Next Steps
*
For example, any corrective actions not completed, follow-up with employees involved, EAP referrals, etc.
Submit
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