Workplace Violence

Liaison Email
example@example.com
Workplace Violent Incident Reporting

Please take a moment to report a suspected workplace violence. Your information will be 100% confidential.
Personal Information
Name*

First NameLast Name
Employee ID Number*
Phone Number*
Please enter a valid phone number.
Liaison*
Incident Details
Incident Location*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

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:*
Was the perpetrator of violence a:*

Customer or client (including students)Family or friend of a customer or clientStranger with criminal intentCoworkerSupervisor or managerPartner or spouseParent or other relativeOther
At the time of the incident, was the employee: (check all that apply)*

Completing usual job dutiesWorking in poorly lit area(s)RushedWorking during a low staffing levelIsolated or aloneUnable to get help or assistanceWorking in a community settingWorking in an unfamiliar or new location
Where did the incident occur?*

Inside the workplaceIn a parking lot or other area outside the workplaceOther
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 spittingAttack with a weapon or object including, but not limited to a firearm, knife, or other objectThreat of physical force or threat of the use of a weapon or other objectSexual assault or threat including, but not limited to rape, attempted rape, physical display, or unwanted verbal or physical sexual contactAnimal attackOther
Were there any injuries?*

YesNo
Consequences of the incident:*

Security or law enforcement was contactedEmergency 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.
Should be Empty:

Workplace Violent Incident Reporting

Personal Information

Incident Details

Workplace Violent Incident Investigation Report