Date of Incident:	Time of Incident:
Specific location where the incident occurred:

Incident Details

Type of Incident
Select from the following options:

Physical Assault	Intimidation
Verbal/Written Threat	Property Damage
Harassment	Other (Specify):

Description of Incident
Provide a detailed description of what happened, including the sequence of events, involved parties, and any relevant context.

type here

Witnesses
List the names and contact information of any witnesses to the incident

WITNESS	CONTACT INFO
type name(s) here	type email, phone or address here

Severity
Select from the following options:

Low	Moderate	High	Severe

Immediate Actions Taken
Describe any immediate actions taken to address the incident, such as contacting security, involving law enforcement, or providing medical assistance.

type here

Follow-Up Actions

Reported to Management
Indicate whether the incident was reported to supervisor or HR

Reported to HR	Reported to supervisor	Reported to both HR and supervisor

Investigation
Describe any steps taken to investigate the incident, including interviews with witnesses or involved parties, review of security footage, etc.

type here

Documentation
Attach any relevant documentation, such as incident reports, witness statements, or photographs.

insert links to reports or images, if applicable, here

Communication
Detail any communication with employees, management, or other stakeholders regarding the incident.

type here

Support Provided
Describe any support provided to employees affected by the incident, such as counseling services or safety planning.

type here

Preventive Measures

Risk Assessment
Indicate whether a risk assessment was conducted following the incident to identify potential contributing factors and prevent future occurrences.

type here

Training
Detail any additional training provided to employees or managers to prevent workplace violence.

type here

Policy Review
Note any updates or revisions made to workplace violence prevention policies or procedures as a result of the incident.

type here

Follow-Up Actions Required

Employee Discipline
If applicable, detail any disciplinary actions taken against individuals found responsible for the incident.

type here

Legal Action

Indicate whether legal action, such as filing charges or seeking a restraining order, is being pursued.

type here

Safety Measures

Describe any additional safety measures implemented to enhance security and prevent similar incidents.

type here

Additional Comments

Provide any additional comments or observations related to the incident or follow-up actions.

type here

Completed By

Name of Employee Documenting Incident:
Employee's Position:
Date: