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:
	

	

	

	

	

JCS, Inc. Workplace Violence Incident Documentation Log        Last revised 4-22-2024                        Page  of 3