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 Violence Incident Report Forms*

The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence.

(Sample/Draft - Adapt to your own location and business circumstances)

Confidential Incident Report

To:____________________ Date of Incident:___________________
Location of Incident:________________
_________________________________

Map/sketch on reverse side or attach

From:_______________ Phone:_________ Time of Incident:_______


Nature of the incident: (xx all applicable boxes)
____Assaults or violent acts: ____ Type "1"____ Type "2" ____ Type "3" ____Other
____Preventative or warning report
____Bomb or terrorist type threat (special checklists attached Yes or No)
____Transportation accident
____Contacts with objects or equipment
____Falls
____Exposures
____Fires or explosions
____Other

Legal counsel advised of incident 
____Yes  ____No
EAP advised 
____Yes   ____No
Warning or preventative measures
____ Yes ____ No
Number of persons affected

    (For each person complete a report; however, to the extent facts are
    duplicative, any person's report may incorporate
    another person's report.)

Name of affected person(s): ________________________ Service date:______________
Position:__________________________ member of labor organization
____Yes ____No
Supervisor: _______________________ has supervisor been notified ____Yes____No
Family: ___________________________ has been notified
____Yes ____No

 
Lost work time ____Yes ____No
Anticipated return to work ____
Third parties or non-employee involvement ____Yes ____No (include contractor and lease employees, visitors, vendors, customers)


Nature of the incident
Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3) location details; (4) equipment/weapon details; (5) weather; (6) other records of the incident (e.g., police report, recordings, videos); (7) the ability to observe and reliability of witnesses; (8) were the parties possibly impaired because of illness, injury, drugs or alcohol (were tests taken to verify same ____Yes ____No); (9) parties notified internally (employee relations, medical, legal, operations, etc.) and externally (police, fire, ambulance, EAP, family, etc.)


Previous or related incidents of this type ____Yes ____No
or by this person ____Yes ____No
Preventative steps ____Yes____No    
OSHA log or other OSHA action required ____Yes ____ No

Incident Response Team:
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________
_____

Team Leader____________________  ___________________________
                         Signature                   Date

*This form was taken from: Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, OSHA Publication 3148, 1996.

 

 

 

 

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