"Workplace Violence Prevention Incident Report Form" - Rhode Island

Workplace Violence Prevention Incident Report Form is a legal document that was released by the Rhode Island Department of Administration - a government authority operating within Rhode Island.

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Download "Workplace Violence Prevention Incident Report Form" - Rhode Island

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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Administration
Division of Human Resources
Workplace Violence Prevention Incident Report Form
Part I through Part V should be completed by the employee reporting the incident and
forwarded to his/her supervisor and the agency’s Human Resources Liaison.
PART I - NATURE OF INCIDENT - (Check all that apply)
☐Verbal
☐Written
☐Electronic ☐Harassment
Threat/Incident:
☐Physical with Injury
☐Physical without Injury
☐Behavioral Observation
☐Information Only
☐Other (Please Describe):
__________________________________________________________________
__________________________________________________________________
Date of Incident: __________________ Approximate Time: _______________
a.m. p.m.
Description of observation, threat, incident, or activity. Continue on separate sheet of paper if necessary.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Page 1 of 6
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Administration
Division of Human Resources
Workplace Violence Prevention Incident Report Form
Part I through Part V should be completed by the employee reporting the incident and
forwarded to his/her supervisor and the agency’s Human Resources Liaison.
PART I - NATURE OF INCIDENT - (Check all that apply)
☐Verbal
☐Written
☐Electronic ☐Harassment
Threat/Incident:
☐Physical with Injury
☐Physical without Injury
☐Behavioral Observation
☐Information Only
☐Other (Please Describe):
__________________________________________________________________
__________________________________________________________________
Date of Incident: __________________ Approximate Time: _______________
a.m. p.m.
Description of observation, threat, incident, or activity. Continue on separate sheet of paper if necessary.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Page 1 of 6
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Administration
Division of Human Resources
PART II - INCIDENT DIRECTED AT
Person(s): ___________________________________________________________________________
Place: ______________________________________________________________________________
Structure: ___________________________________________________________________________
(Type and Location of Structure)
PART III - INCIDENT INITIATED/COMMITTED BY
Person(s): ___________________________________________________________________________
Check all that apply: ☐Male
☐Female
☐Employee ☐Visitor
☐Contractor
☐Patient ☐Student
☐Other: ______________________________________
Title: ___________________________________
Phone Number: ____________________________
Department/Division: __________________________________________________________________
PART IV - TYPE/LOCATION INCIDENT OCCURRED
Type of Contact:
☐In person
☐Telephone
☐Mail
☐Observation
☐Recording
☐E-Mail
☐Fax
☐Other: ________________________
Was the employee alone? ☐Yes ☐No
Location of Incident:
☐Worksite
☐Other: ________________________________________________________
Page 2 of 6
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Administration
Division of Human Resources
Address/Location where incident occurred:
____________________________________________________________________________________
(
Street, City, State, Zip Code)
☐Yes ☐No
Were any threats made before the incident occurred?
Did the employee(s) ever report to the department that he/she was threatened, harassed, or suspicious
☐Yes
☐No
that the responsible person may become violent?
☐Yes
☐No
Was a weapon used?
If yes, what type of weapon? ____________________________________________________________
☐Yes
☐No
Were there injuries?
If yes, who was injured?
1) Name: ________________________________________
Phone: _______________________
Injury Description: _________________________________________________________________
2) Name: ________________________________________
Phone: _______________________
Injury Description: _________________________________________________________________
3) Name: ________________________________________
Phone: _______________________
Injury Description: _________________________________________________________________
Page 3 of 6
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Administration
Division of Human Resources
Witnesses(s) to the incident:
1) Name: ________________________________________
Phone: _______________________
Address: ____________________________________________________________________________
(
Street, City, State, Zip Code)
2) Name: ________________________________________
Phone: _______________________
Address: ____________________________________________________________________________
(
Street, City, State, Zip Code)
3) Name: ________________________________________
Phone: _______________________
Address: ____________________________________________________________________________
(
Street, City, State, Zip Code)
PART V - ACTION TAKEN: SUPERVISOR/OTHER AUTHORITY
What action was/has been taken by the Supervisor/Other Authority?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
☐Yes
☐No
Law enforcement or other outside agencies contacted?
Agency Name: _______________________________________________________________________
Case Number (If Applicable): ___________________________________________________________
Was Employee Assistance Program services offered? ☐Yes ☐No
If yes, when? ________________________________________________________________________
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Administration
Division of Human Resources
Completed By:
Name: ___________________________________________
Date: ___________________________
Signature: ___________________________________________________________________________
Title: ____________________________________________
Phone Number: ____________________
Department/Division:
__________________________________________________________________
Submit this form to:
1) Your immediate Supervisor
2) Your Human Resources Liaison
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