WorkWhile Violent Incident Log (California Only)

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Please provide as much detail as you can regarding the incident you are reporting.

Date of Incident *

YYYY

Time of Incident *

Time

Location of Incident (City, State) *

Which employer were you working for at the time of the incident? *

Description of Incident *

Did the incident happen in one of the following locations?

Workplace

Parking Lot

Other Area Outside the Workplace

Other:

Clear selection

What was the nature of the incident? *

Physical attack

Attack with a weapon

Threat of violence

Sexual assault or threat

Animal attack

Other:

Was security and/or law enforcement contacted? *

Yes

Unsure

What type of violence is associated with this incident? *

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 employees 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.

[OPTIONAL] By default, your submission is anonymous. If you'd like to provide your name and contact information, you may do so here.

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