Fillable Workplace Violence Incident Report (State University of New York College of Agriculture and Technology at Cobleskill)

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Workplace Violence Incident Report (State University of New York College of Agriculture and Technology at Cobleskill)

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The Workplace Violence Incident Report (State University of New York College of Agriculture and Technology at Cobleskill) form is 1 page long and contains:

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U.S.A. forms for State University of New York College of Agriculture and Technology at Cobleskill

BROWSE STATE UNIVERSITY OF NEW YORK COLLEGE OF AGRICULTURE AND TECHNOLOGY AT COBLESKILL FORMS

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Workplace Violence Incident Report
The College will not tolerate any act or threat of violence made in the workplace, on College
property, or while in work status. No person may engage in violent conduct or make threats of
violence, implied or direct, on College property or in connection with College business.
Please check which definition of Workplace Violence most closely matches the incident you
are reporting and then complete the questions below:
The use of force with intent to cause harm, e.g. physical attacks, any unwanted contact
such as hitting, fighting, pushing, or throwing objects
Behavior that diminishes the dignity of others through sexual, racial, religious or ethnic
harassment
An act or threat which was intended to intimidate, harass, threaten, bully, coerce, or cause
fear of harm whether directly or indirectly;
An act or threat made directly or indirectly by oral or written words, gestures or symbols
that communicated a direct or indirect threat of physical or mental harm.
A person, without legal authority, carrying, possessing or using any dangerous weapon on
College property or in College buildings or facilities.
Other (explain below)
Return completed form to Human Resources, Knapp 126 or call (518) 255-5514
Today’s Date_____________
Date of Incident_______________________ Time of Incident______________________
Employee Name________________________________________________________________
Title______________________________________ Workplace Location___________________
What were you doing just prior to the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Incident Description (Minimally include names of involved employees, extent of injuries and
names of witnesses…Attached additional sheets as needed):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Your signature _________________________________
For College use only: Actions taken or being considered as a result of the incident to prevent
further like occurrences or ameliorate current situation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
HR Signature __________________________________________ Date ___________________
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Workplace Violence Incident Report (State University of New York College of Agriculture and Technology at Cobleskill)

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Completed 27 July 2020

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