Workplace Violence Incident Report

This form can be used to report a workplace violence incident. Your responses are confidential, unless you choose to disclose name and contact information.

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* 1. Date and Time of the Incident:

Date / Time

Date

Time

AM/PM

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* 2. Location of the Incident:

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* 3. Address (Include city and state):

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* 4. Type of Incident

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.

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* 5. Was a weapon involved:

Yes

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* 6. Please explain the incident in detail (Include names of people involved, exact location, duration, and any additional information):

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* 7. Was there a physical injury:

Yes

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* 8. If you know the name(s) of the assailant(s), please specify here. If not, please write "Unknown":

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* 9. Did you talk to any Malone team members about the incident? If so, please explain:

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* 10. Contact Information (optional):

Name

Company

City/Town

State/Province

Email Address

Phone Number