Workplace Violence Report - Camacho Facilities Services

Today's Date*

Date of Incident*

Time of Incident

:

Location of Incident*

Street Address Address Line 2 City State ZIP Code

Person Involved 1*

First Middle Last

Purported victim of violent behavior

Person Involved 2

First Middle Last

Alleged perpetrator of violent behavior

Was more than one person exhibiting violent behavior?

Yes
No

How many persons exhibited violent behavior?

Person Involved 3

First Middle Last

Person Involved 4

First Middle Last

Person Involved 5

First Middle Last

Was there a witness to the Incident?

Yes
No

Witness Name

First Last

Witness Phone

Witness Email

Did anyone intervene to protect you from the violent behavior?

Yes
No

Person who intervened to protect the victim.

First Middle Last

Describe Incident Details:

Was professional medical or mental health services offered to Person 1?

Yes
No

Was professional medical or mental health services requested by Person 1?

Yes
No

Medical or Mental Health Professional Name

First Last

Telephone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Were work restrictions issued by professional medical or mental health authority?

Yes
No

Work Restrictions:

First day off work:

Expected date to return to work:

Person Preparing Report

Name*

First Last

Phone

Workplace Violence Incident Report

Person Preparing Report