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This form is to be completed by individuals (City of Chicago)

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CITY OF CHICAGO
VIOLENCE IN THE WORKPLACE INCIDENT REPORT
Office Use Only
Case Number: -----------------------------
This form is to be completed by individuals involved in incidents of violence, as described in the City of
Chicago Violence in the Workplace Policy. After completing this form it should be signed and dated and
submitted to the Violence in the Workplace liaison for the employee’s department.
EMPLOYEE INFORMATION
First Name:
Last Name:
Job Title:
Department:
Phone Number:
INCIDENT INFORMATION
Date of Incident:
Location of Incident:
WHAT IS YOUR ROLE IN THIS INCIDENT?
Note: This form should be filled out individually by only one of the following participants: the person complaining (“Complainant”),
the alleged perpetrator (“Respondent”), or anyone who witnessed the incident or was identified as a witness (“Witness”).
_____ Complainant _____ Respondent* _____
Witness
*If you are the Respondent, you have a right to consult with your union representative or legal counsel before
completing this form.
Description of the Incident
Please describe the incident, and your role
in this incident. Provide details, such as descriptions of any injuries or
property damage. Print legibly below.
Please attach additional pages if needed. Any additional pages should be
signed and dated.
Description of the Incident (continued)
WITNESS INFORMATION
Please provide the name of anyone who was a witness to this incident.
1.
2.
3.
EMPLOYEE SIGNATURE
NOTE: Under the City’s Personnel Rules, you have an obligation to cooperate with the Department of
Human Resources and your department in investigations conducted under the Violence in the
Workplace policy, and to provide complete and truthful information. Failure to meet these obligations
may lead to discipline.
___________________________________________ ________________________________
Signature Date:
___________________________________________
Printed Name
*If you are the Respondent, you have a right to consult with your union representative or legal counsel before
completing this form.
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Completed 2 August 2020

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