Workplace Violence Incident Report
Please note:  If this case is a "privacy concern case", in place of the name of the employee who was the victim of the workplace violence enter PRIVACY CONCERN CASE in the space used for the employee's name.  Privacy concern cases include cases involving:
  • Injury or illness to an intimate body part of the reproductive system
  • Injury or illness resulting from a sexual assault
  • Mental illness
  • HIV infection
  • Needle stick injuries and cuts from sharp objects that are or may be contaminated with another person's blood or other potentially infectious material
  • Other injuries or illnesses, if the employee independently and voluntarily request that their name not be entered on the report
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Date of Incident
MM
/
DD
/
YYYY
Workplace location where incident occurred *
Time of day/shift when incident occurred *
Time
:
Names and job titles of involved employees *
Detailed description of the incident including events leading up to the incident and how the incident ended *
Nature and extent of injuries arising from the incident *
Names of witnesses and their contact information *
Was this workplace violence a result of an interaction with a student?  *
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