Fill - Free fillable Workplace Violence Incident Report Form-1 PDF form

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 ___________________

Fill Online, Printable, Fillable, Blank Workplace Violence Incident Report Form-1 Form