Sample Incident Report Form

This type of form can be used to report any threatening remark or act of physical violence against a person or property, whether experienced or observed. Individuals may be more forthcoming with information if the form is understood to be voluntary and confidential. The form also needs to identify where it should be sent after completion (for example, workplace violence prevention group or safety committee representative).

Date of Incident Year Month Day of Week

 

Location of Incident (map and sketch on reverse side):

 

Name of Victim: Gender:

Male_____ Female_____

Victim Description:

____Employee Job Title__________________________________

____Client

____Visitor

 Member of Labor Organization?

Yes____ No____

Assigned Work Location (if employee)
Supervisor: Has supervisor been notified?

Yes____ No____

Describe the incident.

 

 

 

 

 

 

List any witnesses to the incident (name and phone).
Did the assault involve a firearm? If so, describe.
Did the assault involve another weapon (not a firearm)? If so, describe.
Was the victim injured? If yes, please describe.

 

Who committed the incident (name, if known)? What is his/her status to the victim:
____Stranger

____Personal Relation

____Client/Patient/Customer

 ____Co-worker

____Supervisor

____Other

  

If other, describe:

 

What was the gender of the person(s) who committed the incident? ____Male

____Female

  

Please check any risk factors applicable to this incident. Each company should develop and include a list of potential risk factors that may apply in its worksite. 

What steps could be taken to avoid a similar incident in the future?

(To avoid recreating trauma, sound judgment should be exercised in deciding when to request this information.)

Send completed form to:______________________________________

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Adapted from: Workplace Violence: Awareness and Prevention for Employers and Employees, Washington State Department of Labor and Industries