Index - Catapult EMS

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

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)

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

Eye Color *Required

Age *Required

Gender *Required

Ethnicity *Required

Height *Required

Weight *Required

Distinguishing Mark(s) *Required

Social Media Username(s)/Handle(s) *Required

Are there additional perpetrators of this workplace violence? *Required

Yes No

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

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

Pleasant Valley Elementary School District Workplace Violence Logs

Workplace Violence Log

Workplace Violence Log

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