Workplace Violence Incidents/ Hazards Reporting Form

This form is designed for employees to report workplace violence hazards and/or incidents with the option to report anonymously.


Employee can also report incidents to their supervisor, HR and the Safety Department through the following:


○ Email: HR@sonsray.com and/or safety@sonsray.com

○ Phone: 323-319-1900 x1830


A strict non-retaliation policy is in place, and any instances of retaliation are dealt with swiftly and decisively. An employee who retaliates against a coworker for reporting an incident could face disciplinary actions up to and including termination.

 

General Information

 

Name & title of person affected by violent incident or hazard.

 
 
mm/dd/yyyy
 

Specify - a.m./p.m.

 

Please share as many details as possible. i.e Sonsray, Inc. Headquarters - 23935 Madison St., Torrance, CA 90505 - front lobby

 

Select one of the following four (4) workplace violence types.

 

“Type of Incident” specifically refers to the nature or characteristics of the incident being logged. It does not refer to the type of workplace violence.

 

Details of the Incident/ Hazard

 

Provide a detailed description of the incident and any additional information on the violence incident type or hazard and what it included.

 
 

Write/type what was happening at the time of the incident, including, but not limited to, whether the employee was completing usual job duties, working in poorly lit areas, rushed, working during a low staffing level, isolated or alone, unable to get help or assistance, working in a community setting, or working in an unfamiliar or new location.

 

Results of the Incident/ Hazard

 

Actions taken to protect employees from a continuing threat or from any other hazards identified as a result of the incident. Whether security or law enforcement was contacted and their response.

 

If yes, please explain.

 

Were emergency medical responders other than law enforcement contacted, such as a Fire Department, Paramedics, On-site First-aid certified personnel? If yes, please explain.

 

Hazard Correction

 

i.e. exchanging money with the public

 

i.e. cameras, locked doors, etc.

 

Reporting Person

This form provides the option to report workplace violence incidents and hazards anonymously. If you wish to provide your name for updates, please type your name in the box below.