Form HR 549 Workplace Violence Incident Report - North Carolina

Form HR549 is a North Carolina Department of Public Safety form also known as the "Workplace Violence Incident Report". The latest edition of the form was released in March 1, 2014 and is available for digital filing.

Download an up-to-date fillable Form HR549 in PDF-format down below or look it up on the North Carolina Department of Public Safety Forms website.

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DEPARTMENT OF PUBLIC SAFETY
Print Form
WORKPLACE VIOLENCE INCIDENT REPORT
To be completed by the individual investigating the incident. Return completed for within 7 days following incident to the
DPS Human Resource Office, Workplace Violence Coordinator. Attach victim/witness statements to this form.
Date:
Report submitted by:
Title:
Telephone:
AM
PM
Time:
Date of incident:
Address/Location of Incident:
Individuals involved in the incident (use additional sheet(s) if necessary):
Name:
Name:
Victim or
Assailant
Victim or
Assailant
Title:
Title:
Division:
Division:
Phone:
Phone:
Immediate Supervisor:
Immediate Supervisor:
Assailant Relationship to Employee
Co-worker
Customer/Client
Supervisor
Person In Custody
Former Employee
Stranger
Spouse/Family Member
Other
Reason for Incident: (if known, check all that apply):
Conflict with co-worker(s)/former co-worker
Alcohol/Drugs in the workplace
Conflict with supervisor
Mental health problems
Family/domestic dispute
Reduction in force
Receiving a poor performance appraisal
Demotion
Receiving disciplinary action
Dismissal
Racial Tension
Resisting arrest
Other (specify)
Form HR 549 Workplace Violence Incident Report
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Form last revised March 2014
NC Department of Public Safety

Download Form HR 549 Workplace Violence Incident Report - North Carolina

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