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Conejo Valley Unified School District
Workplace Violence Logs
1400 East Janss Road,, Thousand Oaks, CA 91362
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(805) 497-9511
Workplace Violence Log
Is this an emergency?
*Required
Yes
No
Click Here to Call 911 and follow the steps detailed in your Workplace Violence Prevention Plan. You may complete this log after following these steps
Date of Violent Incident:
*Required
Time of Violent Incident:
*Required
AM
PM
Name of school/campus where workplace violence occured:
*Required
Do you know the location where the violent incident occurred?
*Required
Yes
No
Provide details of the location below (Room Number, Building Number, etc.):
*Required
Describe the threat of violence:
(Check all that apply)
*Required
An incident involving a threat or use of a firearm or other dangerous weapon, including the use of common objects as weapons, regardless of whether the employee sustains an injury
Behavioral or physical conduct, that conveys an intent, or that is reasonably perceived to convey an intent, to cause physical harm or to place someone in fear of physical harm, and that serves no legitimate purpose
Threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury
Verbal or written statement, including, but not limited to, texts, electronic messages, social media messages, or other online posts
Other type of violence
Describe the threat of violence below:
*Required
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
Classification of who committed the violence:
(Check all that apply)
*Required
Coworker
Employee
Family of Friend of Employee
Family or Friend of Student
Manager or Supervisor
Spouse or Partner of Employee
Stranger with Criminal Intent
Student
Other Person(s)
Classify the person(s) who committed the workplace violence in the space below:
*Required
Do you have information about the perpetrator of this workplace violence?
*Required
Yes
No
Perpetrator's Information (Person involved in the workplace violence))
Fill in details where applicable
Full Name
*Required
Address
*Required
Hair Color
*Required
Select Color
Bald
Black
Blonde
Brown
Grey
Red
White
Unknown
Eye Color
*Required
Select Color
Black
Blue
Green
Brown
Hazel
Unknown
Age
*Required
Gender
*Required
Select Gender
Female
Male
Unknown
Ethnicity
*Required
Height
*Required
Height
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
Unknown
Weight
*Required
Select Weight
100 lbs
110 lbs
120 lbs
130 lbs
140 lbs
150 lbs
160 lbs
170 lbs
180 lbs
190 lbs
200 lbs
210 lbs
220 lbs
230 lbs
240 lbs
250 lbs
260 lbs
270 lbs
280 lbs
290 lbs
300 lbs
310 lbs
320 lbs
330 lbs
340 lbs
350 lbs
Unknown
Distinguishing Mark(s)
*Required
Social Media Username(s)/Handle(s)
*Required
Are there additional perpetrators of this workplace violence?
*Required
Yes
No
In the space below, please provide the names and any identifying information of the perpetrator(s):
*Required
0
of 500 Character Count
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 type of incident
Please provide a detailed description of the incident:
*Required
0
of 1000 Character Count
Have you informed anyone of this incident, including, but not limited to HR, your Manager, Security Personnel, or Law Enforcement?
*Required
Yes
No
Name and Title of Person(s) Informed:
*Required
Provide a brief description of the result of this interaction:
*Required
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
Provide your contact information (in accordance with Labor Code)
Fill in details where applicable
Full Name
*Required
Job Title
*Required
Email Address
*Required
Phone Number
*Required
Do you have a photo of the incident to upload?
*Required
Yes
No
Upload Photo
*Required
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Knowingly reporting a false threat is a crime.
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