WORKPLACE VIOLENCE INCIDENT REPORT - Jefferson Lab



Workplace Violence Incident ReportTo be completed by the individual investigating the incident. Return completed form within 2 days following incident to Human Resources. Attach witness statements to this form.Report submitted by: FORMTEXT ?????Date: FORMTEXT ?????General Description: FORMTEXT ?????Telephone: FORMTEXT ?????Date of Incident: FORMTEXT ?????Time: FORMTEXT ?????Address/Location of Incident: FORMTEXT ?????Individuals involved in the incident (use additional sheet(s) if necessary)Name: FORMTEXT ?????Name: FORMTEXT ????? FORMCHECKBOX Victim or FORMCHECKBOX Assailant FORMCHECKBOX Victim or FORMCHECKBOX AssailantTitle: FORMTEXT ?????Title: FORMTEXT ?????Division: FORMTEXT ?????Division: FORMTEXT ?????Phone: FORMTEXT ?????Phone: FORMTEXT ?????Immediate Supervisor: FORMTEXT ?????Immediate Supervisor: FORMTEXT ?????Assailant Relationship to Employee FORMCHECKBOX Co-worker FORMCHECKBOX Former Employee FORMCHECKBOX Other (specify) FORMTEXT ?????Possible Reason for Incident: (If known, check all that apply) FORMCHECKBOX Conflict with co-worker(s)/former co-worker FORMCHECKBOX Receiving corrective action FORMCHECKBOX Conflict with management FORMCHECKBOX Other (specify) FORMTEXT ?????Nature of Incident FORMCHECKBOX Stalking FORMCHECKBOX Engaging in actions intended to frighten, coerce, or induce duress FORMCHECKBOX Destruction of Property FORMCHECKBOX Phyisical Assault - Hitting, fighting, pushing, or shoving FORMCHECKBOX Armed Assault - Use of object as weapon (specify) FORMTEXT ????? FORMCHECKBOX Armed Assault - Use of weapon such as gun, knife, etc. (specify) FORMTEXT ????? FORMCHECKBOX Verbal Harassment FORMCHECKBOX Sexual Harassment FORMCHECKBOX Other (specify) FORMTEXT ?????How was the incident communicated? (Check one or more) FORMCHECKBOX Communicated directly to victim FORMCHECKBOX Verbal FORMCHECKBOX Mail FORMCHECKBOX Note FORMCHECKBOX Email FORMCHECKBOX Communicated to another person FORMCHECKBOX Verbal FORMCHECKBOX Mail FORMCHECKBOX Note FORMCHECKBOX Email FORMCHECKBOX Other (specify) FORMTEXT ?????Victim Injury (Check all that apply) FORMCHECKBOX Physical injury FORMCHECKBOX Physical Injury - Medical care requiredInitial Response or Follow up Activity: (Check all that apply) FORMCHECKBOX Situation defused FORMCHECKBOX Occupational Medicine notified FORMCHECKBOX Security called FORMCHECKBOX Law Enforcement notifiedIf Yes, Name of Agency and Report Number: FORMTEXT ????? FORMCHECKBOX Other (specify) FORMTEXT ????? FORMCHECKBOX Employee Assistance Program referralDescribe Incident in Detail Include what happened, where, who was involved, what you heard, saw, etc. FORMTEXT ?????List Names of Other Witnesses FORMTEXT ?????Signature DatePerson Receiving Witness Statement DateRouting Yes No Name Signature Date FORMCHECKBOX FORMCHECKBOX Group Manager FORMCHECKBOX FORMCHECKBOX Associate Director/Department Head FORMCHECKBOX FORMCHECKBOX Security Manager FORMCHECKBOX FORMCHECKBOX EAPUpon completion of investigation, attach a findings/follow-up document to this form. ................
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