CSUF Workplace Violence Reporting Form

CSUF Workplace Violence Reporting Form

IF THIS IS AN EMERGENCY, CALL or TEXT 911

Please note that submissions made via this form might not be reviewed immediately.

Retaliation. The University strictly prohibits any retaliation for reporting a workplace violence incident or other concern. Any member of the University community who retaliates against someone for reporting an incident is subject to discipline, including and up to dismissal, expulsion and/or removal from campus. If you believe you have been retaliated against because of this report, please contact the University’s DHR administrator at (657) 278-8454.

University community members are encouraged to report acts or threats of violence, each of which will be taken seriously and investigated. All submissions will be sent to CSUF Police Department and Risk Management for review.

To report a physical workplace violence hazard, please use the Campus Safety Report.

Definitions

Threat of Violence: Any verbal or written statement, including, but not limited to, texts, electronic messages, social media messages, or other online posts, or any behavioral or physical conduct, that conveys an intent, or that is reasonably perceived to convey an intent, to cause physical harm or to place someone in fear of physical harm, and that serves no legitimate purpose.

Act of Violence: Any act of violence that occurs in a place of employment.

This term also includes but is not limited to the following:

1. The use of physical force against an individual that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether an individual sustains an injury.

2. An incident involving the use of a firearm or other dangerous weapon, including the use of common objects as weapons, regardless of whether an individual sustains an injury.

The term “act of violence” does not include lawful acts of self-defense or defense of others.

Reporting Party Information

Would you prefer to remain anonymous?*

Remaining anonymous may limit our effectiveness in addressing the concerning behavior.

Yes

First Name

Last Name

Contact Number

Phone

Incident Information

Date of Incident*

Time of Incident*

Please include a.m. or p.m.

Refrain from using military time

Location of Incident*

Type of Incident*

Select

Specific Threat of Violence*

Select

Other (Threat of Violence)

Please provide details regarding the type of threat if it doesn't fit into the category above.

Specific Act of Violence*

Select

Other (Act of Violence)

Please provide details regarding the type of actual violence that occurred if it doesn't fit into the category above.

Violence Type (I-IV)*

Select

Perpetrator Classification*

Please describe your relationship with the person who committed the threat of violence or act of violence against you.

Select

Other (Perpetrator Classification)*

If you selected "Other," please describe your relationship with the person who committed the threat of violence or act of violence against you if it didn't fit into a category above.

Name of Person(s) of Concern

Describe the Violent Incident*

Recalling incidents of this nature may be difficult, but we encourage you to provide as much detail as possible.

Were injuries sustained?*

Select

Describe the injury in detail*

If you sustained an injury or injuries, please describe them in detail.

Was CSUF Police Department contacted?

Select

Did CSUF Police Department respond?

Select

Was security contacted?

This question is not asking if law enforcement was contacted.

Various locations, such as College Park, have security that is not associated with the CSUF Police Department.

Select

Did security respond?

Select

Were emergency medical responders contacted?

Select

Did emergency medical responders respond?

Select

Identify the emergency medical responders

If emergency medical responders other than law enforcement were contacted, identify the other responding agencies or companies that were contacted.

Classification of Circumstances*

Select

Other (Classification of Circumstances)*

If you selected "Other," please describe your circumstances at the time the incident occurred if it didn't fit into a category above.

Witness Name

If applicable

File Upload

Please upload documents, photographs, or videos that you believe would help provide context, data, or evidence regarding your concern.

Drag and drop files here or

Send me a copy of my responses

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