Workplace Violence Incident Log

Date of incident (required)

Time of incident (required)

Location of incident (required)

Workplace Violence Type (required)

Type 1 violence – Workplace violence committed by a person who has no legitimate business at the worksite and includes violent acts by anyone who enters the workplace or approaches employees with the intent to commit a crime.

Type 2 violence – Workplace violence directed at employees by customers, clients, patients, students, inmates, or visitors.

Type 3 violence – Workplace violence against an employee by a present or former employee, supervisor, or manager.

Type 4 violence – Workplace 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.

Incident Type (required)

Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting.

Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object.

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

Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.

Animal attack.

Other

Detail of Incident (required)

Violence committed by (required)

Circumstances of incident (required)

Was law enforcement contacted? (required)

Yes

No

Were there any injuries? (required)

Yes

No

Were emergency services contacted? (required)

Yes

No

Reported by (optional)

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