Workplace Violence Intake Form

Workplace Violence Intake Form

Date of Entry Log

Name of Person Completing Log

Incident Overview

Date of Incident

Time of Inceident

Is this Workplace Violence?

Yes

Incident Location Information

Incident Location

Office/Building

Parking Lot

Off-Site

Home

Location Details

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CENTER

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Incident Detail Information

Incident Classification

• Type 1 - Violence committed by a person who has no legitimate business at the worksite, including violent acts by anyone who enters w/ intent to commit a crime (External Public)

• Type 2 - Violence Directed at employees by customers, clients, patients, students, inmates, or visitors (Participants / Staff)

• Type 3 - Violence against employees by current or former employees, supervisors, or managers (Staff / Staff)

• Type 4 - Violence committed in a workplace by someone who does not work there but who has or had a personal relationship w/ an employee. (Staff's Family/Friend / Staff )

Type 1

Type 2

Type 3

Type 4

Incident Type

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Incident Circumstances

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Subject 1

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Subject 2

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Detail Description of the incident

Security/Law Enforcement Contacted

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