Complaint Assistance

Board Policy & Administrative Regulation 1312.3

Williams Uniform Complaint Procedure

Board Policy 5145.7 Sexual Harassment

Employee Workplace Violence Form

Required

Date of the Incidentrequired

Must contain a date in M/D/YYYY format

Time of the Incidentrequired

Location of the Incidentrequired

What type or types of workplace violence occurred?required

Type 1 - Workplace Violence committed by a person who has no legitimate business at the worksite, and includes violent acts by anyone who enters the workplace or approaches workers with the intent to commit a crime.

Type 2 - Workplace Violence directed at employees by customers, clients, patients, students, inmates or visitors.

Type 3 - Workplace violence against an employee by a present or former employee, supervisor or manager.

Type 4 - Workplace Violence committed in the workplace by a person who does not work there, but has or is known to have had a personal relationship with an employee.

Detailed description of the event: required

What type of workplace violence occurred?required

Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting.

Attack with a weapon or object, including, but not limited to, a firearm, knife or other object.

Threat of physical force or threat of the use of a weapon or other object.

Sexual assault or threat, including, but not limited to rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.

Animal Attack

Other

If other, please describe:

Detailed description of any injury, psychological, trauma, or stress: required

Who committed the violence? (e.g., client, customer, friend, coworker, spouse, etc.)required

What were the circumstances at the time of the incident? (e.g. working regular job duties, rushed, working during low staffing, etc.)required

Where did the incident occur? (e.g., workplace, parking lot, other area outside the workplace.)required

Your Department/Siterequired

Name

First Name

Last Name

Email Address

Job Title

Date form was completed:

Must contain a date in M/D/YYYY format

Supervisor Workplace Violence Form

Required

Incident Report Submission ID required

This is the ID number at the top of the submission email you received.

What were the consequences of the incident, including, but not limited to: required

Was security or law enforcement contacted and their response: required

Actions taken to protect employees from a continuing threat or any other hazards identified as a result of incident:required

Was the Workplace Violence Prevention Plan reviewed after this incident?required

Yes

No

Was the Workplace Violence Prevention Plan revised due to this incident. If so, how?required

Log completed by: requiredSupervisor's Name

First Name

Last Name

Supervisor's Name

Supervisor's Title: required

Email Addressrequired

Please enter your email to receive a copy of your submission for your records.

Date Completed: required

Must contain a date in M/D/YYYY format

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In This Section

Complaint Against Personnel

Uniform Complaint Procedure

Board Policy & Administrative Regulation 1312.3

Uniform Complaint Form

Williams Uniform Complaint Procedure

Board Policy 5145.7 Sexual Harassment

Employee Workplace Violence Form

Supervisor Workplace Violence Form

In This Section

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