2024 | Workplace Violence Reporting Form

Workplace Violence Reporting Form

This form is to be used by employees that have identified an incident, threat or concern related to workplace violence. This form brings the issue to the attention of the management.

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 the employee(s) the action taken and any subsequent actions, as necessary.

To be completed by the individual investigating the incident. Return completed form with 2 days following incident to the University President. Attach witness statements to this form.

General Information

Name of Report submitted by

Date +

General Description

Phone

Address/Location of Incident

Date of Incident +

Campus

Individuals involved in the Incident

First Individual

Victim or

Assailant

Job Title

Department

Phone

Immediate Supervisor

Second Individual

Victim or

Assailant

Job Title

Department

Phone

Immediate Supervisor

Additional Individuals and Information

Classification of Incident (Select One)

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

Type 2 - Committed by a person who does have a legitimate purpose at the worksite.

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.

Classification of Incident Location (Select One)

Indoors (Please Include Building, Name/Room Number)

Outdoors (Please Specify)

Other (Please Explain)

Type of Incident(Select One)

Physical Attack - no weapon/object	Physical Attack - with weapon/object
Physical Assault - Hitting, fighting, pushing, or shoving	Sexual assault/threat (incl. rape, attempted rape, physical display, or unwanted verbal/physical sexual contact)
Threat of physical force and/or threat of use of a weapon/object

Other (Please Explain)

How was the incident communicated? (Select One)

Communicated Directly to the victim

Verbal

Mail

Note

Email

Communicated to another person

Verbal

Mail

Note

Email

Other (Please Explain)

Initial Response or Follow-Up Activity: (Check all that Apply) (Select One)

Law enforcement notified? (If Yes, Name of Agency and Report Number)

Other (Please Explain)

Describe Incident in Detail

Include what happened, where, who was involved, what you heard, saw etc. Also include the circumstances at time of incident (i.e.: was the employee completing usual job duties, was the area poorly lit, was the work being rushed, was the employee working during a low staffing level, was the employee isolated/alone, was the employee able to get help/assistance, was the employee working in a community setting, was the employee working in an unfamiliar/new location, other - please explain).

List Names of Other Witnesses

Signature

clear

Date +

Person Receiving Witness Statement

clear

Date +

Situation defused	Occupational Medicine notified
First Aid Received	Security Called
Employee Assistance Program Resources Provided