8130.2F Workplace Violence Prevention

BRENTWOOD UNION FREE SCHOOL DISTRICT

Workplace Violence Incident Report

Today’s Date: ____________________

Date of Incident: ____________________

Start Time of Incident: ____________________ Ending Time of Incident: __________________

Location of Incident: ______________________________________________________________

Employee Name: ________________________________ Employee ID #: __________________

Job Title: _______________________________________

Names and job titles of involved employees, students, parents, or visitors:

_____________________________________________________________________________________

Names or identifiers of other involved individuals:

_____________________________________________________________________________________

Names of witnesses:

_____________________________________________________________________________________

Describe the events leading up to the incident (attach separate sheet if needed):

_____________________________________________________________________________________

Describe the incident, including how it occurred (attach separate sheet if needed):

_____________________________________________________________________________________

Describe or list any illnesses or injuries:

_____________________________________________________________________________________

By signing this Report, I am certifying that the information contained in it, as well as any attached sheets, is truthful and accurate.

_____________________________

Employee Signature

Dated: _______________________

-------------------------------------------------------------------------------------------------------------------------------

This section is to be completed by the Supervisor, Building Principal, or Human Resources representative.

Name: ________________________________

Job Title: ______________________________

Date Report Received: ___________________

Personal Privacy Case: Yes No