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BFCSD Workplace Violence Incident Report
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* Indicates required question
Date of Incident.
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MM
/
DD
/
YYYY
Time of day/shift when the incident occurred.
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Your answer
Workplace location where incident occurred.
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Your answer
Provide a detailed description of the incident by answering the questions below:
Name of employee reporting the incident (u
nless a ''privacy concern case").
*Note: If the case is a ''privacy concern case," remove the name of the employee who was the victim of the workplace violence and enter "PRIVACY CONCERN CASE" in the space normally used for the employee's name. Privacy concern cases include cases involving: Injury or illness to an intimate body part or the reproductive system; Injury or illness resulting from a sexual assault; Mental illness; HIV infection; Needle stick injuries and cuts from sharp objects that are or may be contaminated with another person's blood or other potentially infectious material; and Other injuries or illnesses, if the employee independently and voluntarily requests that his or her name not be entered on the report.
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Your answer
Names and job titles of involved employees.
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Your answer
Name or other identifier of other individuals involved.
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Your answer
Nature and extent of injuries arising from the incident.
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Your answer
Names of witnesses.
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Your answer
Events leading up to the incident and how the incident ended.
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Your answer
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