RBUSD Workplace Violence Incident Report

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Please use this form to report an incident of violence at an RBUSD work location

Name of person completing this form

Are you completing the form for yourself or someone else?

Self

Another person

Clear selection

What is your email address?

What date did the incident happen?

YYYY

What time did the incident happen?

Time

Where did the incident happen?

What type of violence was committed?

Violence committed by a person with no legitimate business at the worksite

Violence directed at employees by customer, client, patient, student, or visitor.

Violence against an employee by a present or former employee, supervisor, or manager

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

Clear selection

Please provide a description of the incident

Which of the following best describes the person that committed the violence?

Student

Coworker/Staff Member

Family member of a student or staff member

Stranger with Criminal Intent

Supervisor or Manager

Partner or Spouse of the Victim

Other:

Clear selection

Do any of the following circumstances apply to the incident?

Completing usual job duties

Working during a low staffed time

Unable to get help or assistance

Working off site

Working in a new or unfamiliar situation

Other:

Type of incident

Physical attack without a weapon

Attack with a weapon or object

Threat of physical force or threat of the use of a weapon or other object

Sexual assault or threat

Animal attack

Clear selection

Submit

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