AVUSD WORKPLACE VIOLENCE INCIDENT REPORT FORM (WVIRF)

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THIS FORM IS TO BE USED BY EMPLOYEES AND/OR THEIR SUPERVISORS THAT HAVE IDENTIFIED AN INCIDENT, THREAT OR CONCERN RELATED TO WORKPLACE VIOLENCE. THIS FORM BRINGS THE ISSUE TO THE ATTENTION OF MANAGEMENT.

THIS REPORT IS NOT TO BE USED FOR WITNESS STATEMENTS. THERE SHOULD ONLY BE ONE COMPLETED WORKPLACE VIOLENCE INCIDENT REPORT FORM (WVIRF) PER VICTIM PER INCIDENT. IF THERE ARE MULTIPLE VICTIMS, EACH VICTIM SHOULD FILL OUT A SEPARATE REPORT.

IF YOU ARE NOT SURE IF A WVIRF WAS COMPLETED, PLEASE CONTACT HUMAN RESOURCES.

THIS FORM IS NOT INTENDED FOR REASONABLY EXPECTED STUDENT BEHAVIORAL ISSUES. PLEASE REPORT THESE USING OTHER ESTABLISHED SCHOOL REPORTING PRACTICES.

IF YOU ARE NOT SURE IF YOU SHOULD COMPLETE THIS FORM OR WHAT OTHER STEPS YOU NEED TO TAKE, PLEASE REVIEW THIS CHART.

IT IS ILLEGAL FOR THE EMPLOYER TO TAKE ACTION AGAINST AN EMPLOYEE FOR MAKING SUCH A REPORT. THE EMPLOYER MUST INVESTIGATE THE REPORT AND EXPLAIN TO EMPLOYEES THE ACTION TAKEN AND ANY SUBSEQUENT ACTIONS, AS NECESSARY.

Email *

What is your relationship to the victim in the incident? (Witnesses should not be reporting incidents through this form. Please contact your immediate supervisor or the Human Resources Department at 707-895-3774 x 1603 *

I am the victim

I am the victim's principal, director, manager or supervisor; I witnessed the incident, and I am completing this report on behalf of the victim.

I am the victim's principal, director, manager or supervisor; I did not witness the incident, but I am completing this report on behalf of the victim after taking their statement.

This report is being submitted by (first and last name):
*

What is your phone number? *

If you are not the victim, what is the name of the victim? *

On what date did the incident occur?
*

YYYY

At what time did the incident occur (if you are not sure, please estimate the time)?
*

Time

At what location did the incident occur?
*

Where at the facility did the incident occur? *

At workplace, indoors (please include building name/room number in "Other")

At workplace, outdoors (please specify location in "Other")

Other:

Required

Please provide a general description of the incident:
*

Please provide the name (if known) and any additional information about the assailant. If the assailant is a student, please provide the grade or age of the student as well. *

Please provide the name(s) and contact information (if known) of any witnesses.
*

TYPE OF INCIDENT: Please indicate the type of incident that occurred:
*

Type 1: Committed by a person who has no legitimate purpose at the worksite

Type 2a: Committed by a person who does have a legitimate purpose at the worksite (customer, client, patient, inmate, or visitor)

Type 2b: Committed by a student

Type 3: Committed by a present or former employee, supervisor, or manager

Type 4: Committed by a person who does not work at the workplace, but has or is known to have had a relationship with an employee

WHAT HAPPENED DURING THE INCIDENT: Please indicate what happened during the incident (check all that apply):
*

Physical assault - hitting, fighting, pushing, or shoving

Physical assault - with a weapon/object

Threat of physical force and/or threat of use of a weapon/object

Physical sexual assault (including rape, attempted rape, physical display, or unwanted physical sexual contact)

Verbal sexual assault/threats

Harassment or intimidation

Other:

Required

What happened immediately after the incident (check all that apply) *

Situation defused

Law enforcement notified (please include the agency name and report number in "Other")

First aid received

Emergency services (paramedics and/or ambulance) came on site

Company Nurse notified

Other:

Required

Have you reported this incident anywhere else, and if so, where? *

What outcome(s) are you expecting from reporting this incident?

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