September 2017 Page 1 of 3
Workplace Violence Reporting Form
CONFIDENTIAL
Submission Date: (yy/mm/dd)
This form assists the University in documenting complaints of violence reported by a worker.
Submit the
completed form to Occupational Health & Wellness (OHW).
Fax or Send to (519) 780-1796 / ohw@uoguelph.ca
This form will be forwarded to Campus Community Police to initiate an investigation. It will be communicated to Human
Resources and the pertaining employee group.
Refer to the Policy and Program on Violence Prevention in the Workplace at:
https://www.uoguelph.ca/hr/policies/workplace-violence-prevention-program
In an Emergency call extension 2000 or (519) 840-5000 or 911
Complainant:
Last name:___________________________ First name:_____________________ Initial:_____
Employee Student Visitor VolunteerContractor
Department: ____________________________ Building: __________
Phone/Extension: _____________________ Cell: _________________
Employee Group (if applicable) UGFA Unit 2 UGFA Unit 1 CUPE 1334CUPE 3913Exempt
ONA OSSTF/TARA UNIFOR UGFSEA PSA OPSEU USW Other (Specify) _________________
Date and Time of Incident: _________________________________________________
Where Did the Incident Occur?
Guelph Campus Ridgetown Campus Research Station:_______________________Other: ____________________________
Were the Campus Police/Local Policing Authority notified at the time of the Incident? Yes No
Name of Supervisor: _________________________________ have you notified your Supervisor? Yes No
Was an Injury Incurred? Yes No
If YES, What Was the Injury? ___________________________________________________
Select part of body and indicate Right (R) Left (L), both (B) or Quantity Injured in the box:
Head Teeth Pelvis Elbow Upper Back Knee Toes
Face Neck Shoulder Wrist Lower Back Lower Leg Other__________
Eye Abdomen Upper Arm Hand Hip Ankle
Ear Chest Lower Arm Fingers Upper Leg Foot
Treatment of Injury:
First Aid (OHW or Department) Emergency Room Physician /ClinicStudent Health ServicesNo Treatment Required
Did you see a Medical Professional? No Yes
If YES, Date of Visit: ________________________________
Name/Address/Phone Number of Medical Profession:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Respondent(s):
Last Name: __________________________ First Name: ____________________ Initial: ______
Last Name: __________________________ First Name: ____________________ Initial: ______
Last name: __________________________ First Name: ____________________ Initial: _______
Witness Information, if any:
Name: _______________________________ Dept: ____________________ Phone/Ext.: _________
Name: _______________________________ Dept: ____________________ Phone/Ext.: _________
Name: _______________________________ Dept: ____________________ Phone/Ext.: _________
Provide a Brief Description of the Incident:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Do You Have Any Other Safety Concerns?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Reported By: __________________________________ Signature: ____________________________________
September 2017 Page 2 of 3
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September 2017 Page 3 of 3
Date: (yy/mm/dd) ______________________________
Report Received By: _____________________________ Date Received: _______________________________
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