Violence Incident Report Form

Date of Incident(Required)
Time of Incident(Required)
:
Name of Employee Involved/Witness(Required)
Type of Assault(Required)

Police Called
Person(s) involved seeing a doctor
Medical attention, first aid obtained?
Senior Management Informed
Investigation conducted?
This Report filed with Management?
Information about the assailant:

Name of assailant (if known)
Address of assailant (if known)
Was the assailant involved in previous incidents?
Are measures in place to prevent a recurrence?