Workplace Violence Log

Select the violence type (as described in Labor Code): (Check all that apply) *Required

“Type 1 violence,” which means workplace violence committed by a person who has no legitimate business at the worksite, and includes violent acts by anyone who enters the workplace or approaches workers with the intent to commit a crime

“Type 2 violence,” which means workplace violence directed at employees by customers, clients, patients, students, inmates, or visitors

“Type 3 violence,” which means workplace violence against an employee by a present or former employee, supervisor, or manager

“Type 4 violence,” which means workplace violence committed in the workplace by a person who does not work there, but has or is known to have had a personal relationship with an employee

Please provide a detailed description of the incident: *Required 0 of 1000 character count

Classification of who committed the violence: (Check all that apply) *Required

Contracted Vendor Employee Family of Friend of Employee Family or Friend of Student Manager or Supervisor Partner or Spouse of Employee Stranger with Criminal Intent Student Other

Classification of circumstances at the time of the incident, employee was: (Check all that apply) *Required

Completing usual job duties Isolated or alone Rushed Working during a low staffing level Working in a community setting Working in an unfamiliar or new location Working in poorly lit areas Unable to get help or assistance Not Applicable

Select the type of incident: (Check all that apply) *Required

Animal Attack Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact Threat of physical force or threat of the use of a weapon or other object Other

Did the employee notify anyone, including but limited to, HR, Management, Security Personnel or Law Enforcement of this instance of Workplace Violence? *Required

Yes No

Provide a detailed description of the consequences of the incident, including, but not limited to Actions taken to protect employees from a continuing threat or from any other hazards identified as a result of the incident: *Required 0 of 1000 character count

In compliance with the requirements of Labor Code, the person completing this log must provide their personal contact information in the following fields. *Required

I understand

In accordance with Labor Code, the person completing this log must provide the following information:

Fill in details where applicable:

Full Name (Of Person Completing the Log) *Required

Job Title (Of Person Completing Log) *Required

Email Address *Required

Phone Number (Of Person Completing the Log) *Required

Workplace Violence Log

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