PUSD Employee Workplace Violence Reporting Form

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Complete this form to report a Workplace Violence report (not student related). You may submit your report using this form or can contact Alicia Bush Supervisor, Site Safety at the Workplace Violence Referral Line at (925-473-3141).

If you are the victim of workplace violence, are in need of immediate support or have been injured, call 9-1-1 or seek treatment

Email *

Name (Optional):

Gender: *

Female

Male

Decline to state

Required

Occupation / Position:

Department / Work Site / Job Site - Where did the violence happen?: *

Detailed description of where incident occurred (i.e. empty hallway, warehouse bathroom): *

Date / time of the Incident: *

Type of Incident / What happened? (Check all that apply) *

Grabbed

Kicked

Hit with an object

Shot (or attempted)

Threatened with weapon

Bomb Threat

Arson

Vandalism (employers property)

Pushed

Scratched

Bitten

Sexually Assaulted

Animal Attack

Verbally Harrassed

Vandalism (Own Property)

Slapped

Hit with fist

Knifed (or attempted)

Assaulted with a weapon

Verbally Threatened

Robbery

Other

Required

What happened (Narrative)? *

Name of the perpetrator(s) / Any Identification? *

Definitions of Violent Incident Types - Which type of person threatened or assaulted the employee(s)? (Select one):

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, 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.

Required

Was a weapon used? *

YES

Required

If a weapon was used, what type of weapon was it? How was the weapon obtained?

Were you working alone? *

YES

Required

If no, who was/were with the employee(s) that may have witnessed the incident? (Please list any witnesses)

Were there threats made before the incident occurred? *

YES

Required

If yes, was it ever reported to the employee’s supervisor or manager that the employee(s) was/were threatened, harassed, or was/were suspicious that the attacker may become violent?

Are you willing to testify against the Respondent in Court to obtain a restraining order?

YES

Required

If you are willing to testify as a Complainant you) against the Respondent (person causing the harm), you will need to identify yourself as an anonymous complaint will not be accepted by the court.

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