Anonymous: Workplace Violence Incident Reporting Form
In adherence to our Workplace Violence Prevention Plan (WVPP), we maintain a steadfast commitment to thwarting incidents of aggressive conduct, menacing behavior, and violence within our professional environment. In the event that you have observed any form of threat or act of workplace violence on our premises and opt not to document it in the provided WVPP Incident Log, kindly complete this anonymous form. It is important to note that any unfounded reports may result in disciplinary measures being undertaken.

Definitions of Violence Incident Types: 

Type 1 Violence - 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 violence - Workplace violence directed at employees by customers, clients, patients, students, parents, inmates, or visitors.
Type 3 violence - Workplace violence against an employee by a present or former employee, supervisor, or manager.
Type 4 violence - 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.
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Date the incident occurred: *
MM
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YYYY
Time when the incident occurred: *
Time
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Location where incident occurred: *
Were you a witness to the incident: *
Using the definitions listed above, please identify the Workplace Violence Type(s) that occurred:

 *
If known, who was the aggressor? *
Please provide a detailed description of the indent (If checked "Other" in previous question, please identify here):  *
Who is the victim? *
Please provide a detailed description of the incident: *
Have you reported the incident to anyone? If so, please indicate who in the space provided. *
By completing this form, I certify all information is true and correct to the best of my knowledge. *
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