Workplace Violence Incident Report
This document is intended for the methodical reporting of workplace violence incidents within [Your Company Name]. It plays a crucial role in documenting incidents involving aggression, threats, or violence in the workplace, ensuring a timely and appropriate response.
Key Instructions:
1. Accuracy
Ensure all sections are filled with accurate and factual information. Rely on direct observation or verified sources.
2. Confidentiality
Maintain the confidentiality of the information provided. This report is for internal use and should be shared only with authorized personnel.
3. Response and Follow-up
Utilize this report to support necessary response actions and follow-up measures, including immediate safety steps, investigation, or policy revisions.
4. Support
For assistance in completing this report or queries regarding procedures, contact [Your Company's Security or Human Resources Department].
Submit to: [Designated Department or Individual] at [Your Company Name]. The information will be used for immediate action and for developing future preventive strategies.
Incident Details
Section | Details |
Date of Incident: | [Month Day Year] |
Time of Incident: | [HH: MM AM/PM] |
Location of Incident: | [Break Room, Your Company Address] |
Nature of Violence: | [Verbal Altercation escalating to Physical Assault] |
Description of Incident: | [A verbal altercation between John Doe and James Smith over work schedules escalated, leading to Doe physically pushing Smith against the wall. Quick intervention by coworkers de-escalated the situation.] |
Persons Involved: | [John Doe (Aggressor), James Smith (Victim)] |
Immediate Response
Section | Details |
Actions Taken: | [Emergency procedures activated, security contacted, etc.] |
Medical Assistance: | [First aid provided, medical team called, etc.] |
Law Enforcement Contacted: | [Yes/No, details if applicable] |
Follow-Up Actions Recommended
Section | Details |
Investigation of Incident | [Steps to investigate the incident] |
Workplace Safety Measures | [Suggestions for enhancing workplace safety] |
Training and Awareness Programs | [Recommended training or workshops] |
Report Submission:
Submitted To: ______________________[Name/Department]
Submission Date: ___________________[Month Day Year]
Signature of Reporting Individual: ____________________
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