PE – Violence in the Workplace Incident Report Form
CITY OF LITTLE ROCK
VIOLENCE IN THE WORKPLACE INCIDENT REPORT FORM
Department: Date/Time of Incident:
Physical Address of Incident:
Names of Persons Involved: (Include Address and Phone # of Non-City Employees)
1.
2.
3.
(Use reverse side for additional names)
Type of Incident (Check): Physical Threat Property Threat Physical Assault
Description of Incident:
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Actions Taken (check):
Police Notified Human Resources Notified Disciplinary action(s) pending
Administrative Leave EAP Referral Suspended Terminated
Name (print): Title:
Date: Signature:
This Incident Report Form must be completed and forwarded to Human Resources Risk
Management Division within 24 hours of Incident Occurrence
