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4CD Violent Incident Log

This log must be used for every workplace violence incident that occurs in our workplace. At a minimum, it will include the information required by LC section 6401.9(d).

The information that is recorded will be based on:
1. Information provided by employees who experience the incident of violence.
2. Witness statements.
3. All other investigation findings.

All information that personally identifies the individual(s) involved will be omitted from this log, such as names, addresses (physical or electronic), telephone numbers, social security numbers, and student or employee ID numbers.
1.Please enter the date and time of the incident.
Date / Time
Time
:
2.Please enter the location of the incident.
3.Select the Workplace Violence Type
4.Check which of the following describes the type(s) of incident.
5.Please provide a detailed description of the incident and any additional information on the violence incident type and what it included. Continue on separate sheet of paper if necessary. Remember not to include information that personally identifies any individuals involved.
6.Workplace violence committed by: ____________________________________
[For confidentiality, only include the classification of who committed the violence, including whether the perpetrator was a client or customer, family or friend of a client or customer, stranger with criminal intent, coworker, supervisor or manager, partner or spouse, parent or relative, or other perpetrator.]
7.Circumstances at the time of the incident: _________________________________
[Write/type what was happening at the time of the incident, including, but not limited to, whether the employee was completing usual job duties, working in poorly lit areas, rushed, working during a low staffing level, isolated or alone, unable to get help or assistance, working in a community setting, or working in an unfamiliar or new location.]
8.Where the incident occurred: ________________________________
[Where the incident occurred, such as in the workplace, parking lot or other area outside the workplace, or other area.]
9.Consequences of the incident, including, but not limited to whether security or law enforcement was contacted and their response and any actions taken to protect employees from a continuing threat or from any other hazards identified as a result of the incident: _________________________________________
10.Were there any injuries?
11.Were emergency medical responders other than law enforcement contacted, such as a Fire Department, Paramedics, On-site First-aid certified personnel?
12.Did the severity of the injuries require reporting to Cal/OSHA?
13.What is your name? (The person completing Violence Incident Log)
14.What is your title?
15.Please type your name and add the date to serve as your electronic signature.