FESD Workplace Violence Incident Report Form

The District prohibits workplace violence and will not tolerate violence, threats of violence, or intimidating conduct in the workplace. Workplace violence is any physical assault or acts of aggressive behavior occurring where an employee performs any work-related duty in the course of their employment including, but not limited to: 

a) An attempt or threat, whether verbal or physical, to inflict physical injury upon an employee; 

b) Any intentional display of force which would give an employee reason to fear or expect bodily harm;

c) Intentional and wrongful physical contact with an employee without their consent that entails some injury;

d) Stalking an employee with the intent of causing fear of material harm to the physical safety and health of the employee when the stalking has arisen through and in the course of employment. 

Lawful acts of self-defense are not considered workplace violence.

Please complete the form below to report a workplace violence incident. Incidents may also be submitted in person at the FESD office (534 12th Street, Fortuna), emailed to superintendent@fortunaesd.com, or by contacting FESD Human Resources at (707) 725-2293.
Email *
Name of individual completing form *
Phone number of individual completing form *
Position and work location of the person completing form *
Date of incident *
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Time of incident *
Time
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Location of Incident *
Classification of the person against whom the incident is being reported *
Provide a detailed description of the incident, including events leading up to the incident and how the incident ended. *
Please note names and contact information of any witnesses who may have observed the incident(s).
Describe the nature and extent of any injuries arising from the incident, including the name of the individual(s) injured *
Detail the actions that the District has taken or is considering in response to this incident of workplace violence  *
I certify that the information provided in this statement is true to the best of my knowledge.
 *
Required
Date submitted *
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Electronic Signature *
Submit
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