WORKPLACE VIOLENCE INCIDENT REPORT TEMPLATE

REPORTED BY:	DATE OF REPORT:
TITLE / ROLE:	INCIDENT NO.:

WORKPLACE VIOLENCE INCIDENT INFORMATION
DATE OF INCIDENT:	TIME OF INCIDENT:
NAME OF PERSON DEMONSTRATING PROHIBITED BEHAVIOR:
NAME OF VICTIM:
LOCATION:
SPECIFIC AREA OF LOCATION:
ADDITIONAL PERSON(S) INVOLVED:
WITNESSES:
INCIDENT DESCRIPTION INCLUDING ANY EVENTS LEADING TO OR IMMEDIATELY FOLLOWING THE INCIDENT:
NAMES OF SUPERVISORY STAFF INVOLVED ALONG WITH THEIR RESPONSE TO THE INCIDENT:
RESULTING ACTION EXECUTED, PLANNED, OR RECOMMENDED:

POLICE REPORT FILED?	PRECINCT:
REPORTING OFFICER:	PHONE:
POLICE ACTION TAKEN:
REPORTING STAFF NAME:	REPORTING STAFF SIGNATURE:	DATE:
SUPERVISOR NAME:	SUPERVISOR SIGNATURE:	DATE:

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