Fillable 200-1-7F - ECSU Policy Manual Adopted 6-14-05

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200-1-7F - ECSU Policy Manual Adopted 6-14-05

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200.1.7[F]
Adopted: 03/07/06
ELIZABETH CITY STATE UNIVERSITY
Workplace Violence Report Form
Division: ______________________________________________________________________
Division Head: __________________________________________________________________
Date of Incident: ________________________________________________________________
Date of Report: __________________________________________________________________
Person Submitting Report: _________________________________________________________
Title: __________________________________________________________________________
Telephone number: _______________________________________________________________
Type of incident: (check all that apply)
Threat:
□
Communicated directly to victim
□
Communicated to another person
□
Other (specify) ______________________________________________
__________________________________________________________
□
Verbal
□
Mail
□
Email
□
Note
Intimidation:
□
Stalking.
□
Engaging in activity intended to frighten, coerce, or induce stress
□
Other (specify) ___________________________________________________________
Physical Attack:
□
Hitting, kicking, fighting, pushing, or shoving
□ U
se of object as weapon
□
Use of weapon such as a gun or knife
□
Other (specify) ___________________________________________________________
. Property Damage:
□
Damage to State property
□
Damage to personal property
□
Other (specify) __________________________________________________________
_______________________________________________________________________
200.1.7[F]
VICTIM(S) INFORMATION:
Total number of victims: ____________
List total number for each
_____ Physical injuries
_____ Medical care required
_____ Workers’ compensation claim filed
_____ Trauma/Emotional Injuries
_____ EAP/Psychological care provided
_____ Attended Trauma Debriefing
Name of victim _________________________________________
Name of victim _________________________________________
PERPETRATORS INFORMATION (if known)
□
Employee
□
Supervisor
□
Former employee
□
Partner/family member of employee
□
Customer/client
□
Stranger
If perpetrator was employee, supervisor, or former employee, complete the following:
Length of employment:
□
Less than 6 months
□
5-10 years
□
Less than 2 years
□
over 10 years
□
2-5 years
Have other reports been made regarding this perpetrator?
□
Yes
□
No
Please attach copies of previous reports with this document if applicable.
Name of perpetrator _________________________________________
Name of perpetrator _________________________________________
WITNESSES INFORMATION (if any)
Name: ____________________________________
Phone Number: _____________________________
Name: ____________________________________
Phone Number: _____________________________
Name: ____________________________________
Phone Number: _____________________________
200.1.7[F]
REASON FOR INCIDENT: (check all that apply)
□
Conflict with co-worker(s)
□
Alcoho1/drugs in the workplace
□
Conflict with supervisor
□
Mental Health problems
□
Family/Domestic dispute
□
Dispute over services
□
Receiving poor performance evaluation
□
Dismissal
□
Receiving disciplinary action
□
Other ____________________________
□
Racial tension _________________________________
INITIAL RESPONSE:
□
Situation defused
□
Workplace Violence Coordinator
□
Security called notified
□
Police called
□
EAP consulted
□
Other _________________
□
Employee on Investigative Status with
Pay
ACTION TAKEN
□
Written warning
□
Dismissal
□
Suspension
□
Restraining Order
□
Transferred employee
□
Charges filed
□
Mediation
□
Other _____________________
□
No action taken ___________________________
NARRATIVE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________
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200-1-7F - ECSU Policy Manual Adopted 6-14-05

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Completed 16 November 2019

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