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
Page 1 of 2
Form last revised March 2014
NC Department of Public Safety
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
Page 1 of 2
Form last revised March 2014
NC Department of Public Safety
Type of Incident (Check one or more)
Threat
Communicated directly to victim
Verbal
Mail
Note
Email
Communicated to another person
Verbal
Mail
Note
Email
Other (specify)
Intimidation
Stalking
Engaging in actions intended to frighten, coerce, or induce duress
Other (specify)
Physical Attack
Hitting, fighting, pushing, or shoving
Use of object as weapon (specify)
Use of weapon such as gun, knife, etc. (specify)
Other (specify)
Check if victim sustained physical or traumatic/emotional injury in any of the following categories:
Physical injury
Trauma/Emotional injury
Medical care required
Death
Initial Response: (Check all that apply)
Situation defused
Medical Director notified
Security called
Member Assistance Team notified
Workplace Violence Coordinator notified
Employee Assistance Program referral
Law Enforcement notified
If Yes, Name of Agency and Report Number:
Other (specify)
Follow-up Response: (Check all that apply)
Medical treatment provided to victim
Victim referred to counseling
Medical treatment provided to assailant
Assailant referred to counseling
Workers' Compensation claim filed
Form HR 549 Workplace Violence Incident Report
Page 2 of 2
Form last revised March 2014
NC Department of Public Safety

Download Form HR 549 Workplace Violence Incident Report - North Carolina

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