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Violence Incident Report Forms*
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Sample 1
The following items serve merely as an example of what might be used or modified by
employers in these industries to help prevent workplace violence.
(Sample/Draft - Adapt to your own location and business circumstances)
Confidential Incident Report
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| To:____________________ |
Date of Incident:_______________ |
Location of Incident (Map/sketch on reverse side or attached):
___________________________________________________________ |
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| From:_______________ |
Phone:_________ |
Time of Incident:_______ |
Nature of the incident: (xx all applicable boxes)
____Assaults or violent acts: ____ Type "1" ____ Type "2" ____ Type "3" ____ Other
____Preventative or warning report
____Bomb or terrorist type threat (special checklists attached Yes or No)
____Transportation accident
____Contacts with objects or equipment
____Falls
____Exposures
____Fires or explosions
____Other |
Legal counsel advised of incident
____ Yes ____ No |
EAP advised
____ Yes ____ No |
Warning or preventative measures
____ Yes ____ No |
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| Number of persons affected ____ |
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(Complete a separate report for each person; however, to the extent facts are duplicative, any person's report may incorporate another
person's report.)
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Name of affected person(s):
________________________ |
Service date:______________ |
| Position:__________________________ |
member of labor organization
____ Yes ____ No |
| Supervisor:_______________________ |
has supervisor been notified
____ Yes ____ No |
| Family:___________________________ |
has family been notified
____ Yes ____ No |
Lost work time ____ Yes ____ No
Anticipated return to work ____
Third parties or non-employee involvement ____ Yes ____ No (include contractor and lease employees, visitors, vendors, customers)
Nature of the incident
Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3) location details; (4) equipment/weapon details;
(5) weather; (6) other records of the incident (e.g., police report, recordings, videos); (7) the ability to observe and reliability
of witnesses; (8) were the parties possibly impaired because of illness, injury, drugs or alcohol (were tests taken to verify same
____ Yes ____ No); (9) parties notified internally (employee relations, medical, legal, operations, etc.) and externally (police, fire,
ambulance, EAP, family, etc.)
Previous or related incidents of this type ____ Yes ____ No
or by this person ____ Yes ____ No
Preventative steps ____ Yes ____ No
OSHA log or other OSHA action required ____ Yes ____ No
Incident Response Team:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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Team Leader:____________________ |
___________________________ |
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Signature |
Date |
*Source: Reprinted with permission of Karen Smith Keinbaum, Esq., Counsel to the Law Firm
of Abbott, Nicholson, Quilter, Esshaki & Youngblood. P.C., Detroit, MI. |
Sample 2
The following items serve merely as an example of what might be used or modified by employers in these
industries to help prevent workplace violence.
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A reportable violent incident should be defined as any threatening remark or overt act of physical violence against a person(s) or
property whether reported or observed. |
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Date:_________________________
Day of Week:__________________
Time:_________________________
Assailant: ____ Female ____ Male
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Specific Location:_______________
______________________________
______________________________
______________________________
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Violence Directed Toward: ____ Patient ____ Staff ____ Visitor ____ Other
Assailant:
____ Patient ____ Staff ____ Visitor ____ Other
Assailant's Name:________________________________________________
Assailant:
____ Unarmed ____ Armed (weapon)
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Predisposing Factors: |
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____ Intoxication
____ Grief Reaction
____ Gang Related
____ Other (Describe) |
____ Dissatisfied with Care/Waiting Time
____ Prior History of Violence |
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Description of Incident:
____ Physical Abuse
____ Verbal Abuse
____ Other
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Injuries:
____ Yes
____ No
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Extent of Injuries:____________
___________________________
___________________________
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Detailed Description of the Incident:____________________________________
__________________________________________________________________
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Did Any Person Leave the Area because of Incident?
____ Yes ____ No ____ Unable to Determine
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Present at Time of Incident?
____ Police ______________________________ Name of Department
____ Hospital Security Officer
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Needed to Call:
____ Police ______________________________ Name of Department
____ Hospital Security
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Termination of Incident:
Incident Diffused
Police Notified
Assailant Arrested
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____ Yes ____ No
____ Yes ____ No
____ Yes ____ No |
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Disposition of Assailant:
Stayed on Premises
Escorted off Premises
Left on Own
Other
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____
____
____ |
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Restraints Used: ____ Yes ____ No
Type:_________________________
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Report Completed By:________________________ Title:__________________
Witnesses:________________________________________________________
Supervisor Notified:___________________________________ Time:_________
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Please put additional comments, according to numbered section, on reverse side of form.
Source: Reprinted with permission of the Metropolitan Chicago Healthcare Council, Guidelines for Dealing with
Violence in Health Care, Chicago, IL, 1995.
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