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Workplace Violence Reporting Form

 

Student Enrollment

Required

Employee Information

Employee Namerequired
First Name
Middle (optional)
Last Name

 

Supervisors Information

Enter the Employee Supervisors Name:required
First Name
Last Name
Did the workplace violence incident result in an injury?required

 

Incident or Injury Information

0 / 1000
(Must contain a date in M/D/YYYY format)
0 / 5000

 

Individuals Involved in the Incident

Involvement:required
Name:required
First Name
Middle (optional)
Last Name

 

 

Involvement:
Name:
First Name
Middle
Last Name
Additional Names:

 

 

Involvement:
Name:
First Name
Middle
Last Name
Add Names:

 

 

Involvement:
Name:
First Name
Middle
Last Name

 

 

Workplace Violence Types

Type I 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 workers with the intent to commit a crime.

Type II Violence: Workplace violence directed at employees by customers, clients, patients, students, or visitors.

Type III Violence: Workplace violence against an employee by a present or former employee.

Type IV 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 the employee.

Select the type of workplace violence:required
What type of violent incident occurred?requiredCheck all that apply.
Check all that apply.
Was a weapon used?required
0 / 5000
0 / 5000
Were there any threats made before the incident occurred?required
0 / 5000
Are you willing to testify against the Respondent in Court to obtain a restraining order?required

 

 

Employee's Injury/Illness Report

To report an injury, complete the form below. This information is required in addition to the information provided in the Workplace Violence Reporting form. After completing the form, report your injury to Company Nurse at (877) 518-6702. These steps should be completed even if no medical treatment is required and you are reporting as an injury incident only.
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Employee's Dominant Hand:required
Are you seeking medical treatment?required

If no medical treatment is needed, the employee's signature below acknowledges that this is solely an Incident Report and confirms the following:

  • I have not lost any time from work beyond the incident day.
  • I have been offered medical treatment but decline to see a physician at this time.
  • I have been informed that I have one (1) year from the date of this incident to seek medical treatment.
  • I will notify the Company Nurse hotline immediately at (877) 518-6702 if I wish to request medical treatment.
  • I will review the DWC-1 for more information on the worker's compensation process.

 

 

Electronic Signature:required
Signature:required
First Name
Middle (optional)
Last Name
(Must contain a date in M/D/YYYY format)

 

 

Questions? Need Help?

Contact your Safety Support Specialist.

Jennifer Flores

SAFETY COMPLIANCE OFFICER
Office: 559-730-7514
Extension: 11382
Main: (559) 730-7300