Cayucos School Workplace Violence Incident Report Form

Workplace violence is any act of violence or threat of violence that occurs in a place of employment and includes, but is not limited to the threat or use of physical force that results in, or has a high likelihood of resulting in injury, psychological trauma or stress OR an incident involving the threat or use of a firearm or other dangerous weapon including the use of common objects as weapons.

Lawful acts of self-defense are not considered workplace violence.

Please complete the form below. Required fields marked with an asterisk *

Date of Incident*

Answer Required

Time of Incident*

Answer Required

Exact location of Incident*

Answer Required

Type of Violence*

Answer Required

Type 1: 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 directed at employees by customers, clients, students, or visitors

Type 3: Violence against an employee by a present or former employee, supervisor, or manager

Type 4: 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

Detailed description of Incident*

Answer Required

Classification of the person against whom allegations are being reported*

Answer Required

Student

Family or Acquaintance of Student

Stranger

Supervisor

Fellow employee

Former employee

Family or Acquaintance of Employee or Former Employee

Consultant or Independent Contractor

Other:

Classification of where Incident occurred. Please check all that apply.*

Answer Required

Worksite (office, classroom, etc.)

Playground

Parking Lot

Other:

Did the incident involve any of the following? Please check all that apply.*

Answer Required

Physical attack without a weapon

Physical attack with a weapon

Threat of physical force or threat of use of weapon

Sexual assault or threat of sexual assault

Animal attack

Other:

What was the consequence of the incident? Please include detailed description below including whether or not security or law enforcement was called and what actions were taken to protect individuals from any continuing threat.*

Answer Required

Name of person completing this log:*

Answer Required

Title of person completing this log*

Answer Required

Contact phone and email of person completing this log.*

Answer Required

Date of this entry into log **

Answer Required

Please fix the highlighted areas below before submitting.

Cayucos School Workplace Violence Incident Report Form