Section 1: Information About the Individual Completing This Log

First Name *

Last Name *

Job Title

Date Completed

Section 2: Information About the Incident

Date of Incident

Time of Incident

Location of Incident

Classify the nature of the location (e.g., workplace, parking lot, area outside of workplace, or other area):

Workplace Violence Type (Check one box

Type 1 – Violence committed by a person who has no legitimate business at the workplace.

Type 2 – Violence committed by a customer, client, patient, student, inmate or visitor.

Type 3 – Violence committed by a present or former employee, supervisor or manager.

Type 4 – Violence committed by a nonworker with a personal relationship with the employee.

Classify the type of person committing the violence (e.g., customer/client or their family member, coworker, spouse, parent or other family member or stranger with criminal intent):

Type of Incident (Check all boxes that apply):

Physical attack without a weapon (e.g., punching, kicking, spitting, biting, choking, grabbing or pushing)

Attack with a weapon or other object (e.g., firearm or knife)

Threat of physical force or use of weapon or other object

Sexual assault or threat of sexual assault (e.g., rape, attempted rape, or physical display)

Animal attack

Other

Type of Incident Other

Describe the incident in detail*

*The description must include a classification of circumstances including, but not limited to, whether the employee was completing usual job duties, working in poorly lit areas, rushed in their duties, working during a low staffing level, isolated or alone, unable to get help or assistance, working in a community setting, or working in a new or unfamiliar location.

Section 3: Consequences of the Incident

law enforcement were contacted

Check this box if security or law enforcement were contacted.

If you checked the box above, complete a description of their response:

Identify below all actions taken to protect employees from a continuing threat of violence or any other hazards identified as a result of this incident:

Identify any other consequences, if any, of this incident

Workplace Violence Incident Log