Burton School District WVPP Incident Log

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This form is for reporting any incidents for the Workplace Violence Prevention Plan (WVPP) (SB553). Please ensure that you also complete the required incident forms for Human Resources for any Worker's Comp issue.

Name *

Email Address *

Where did the incident occur? *

Date of Incident *

YYYY

Time of Incident *

Time

Names of the people involved *

Type of Workplace Violence *

Type 1-Criminal Intent (Outside person with no connection)

Type 2-Student/Parent to Staff

Type 3-Staff to Staff

Type 4-Outside person to staff (Outside person has a connection to staff-i.e. spouse)

Type of Incident *

Physical Attack- NO Weapon/Object

Physical Attack- With Weapon/Object

Threat of Physical Force and/or Threat of use of Weapon/Object

Sexual Assault/Threat (Including Rape, Attempted Rape, Physical Display or Unwanted Verbal/Physical Contact)

Describe the Incident. Please use as much as detail as possible *

Please List Any Witnesses *

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