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Printable Employee Incident Report Form




Employee Incident Report



Employee Incident Report


Date: ____/____/_______

Name:

________________________________

Phone:

________________________________

Address: _________________________

City: __________ State: ___ Zip: ____

E-mail:

________________________________




Individuals that were involved in the incident:

Name:

________________________________

Phone:

________________________________

Address: _________________________

City: __________ State: ___ Zip: ____

E-mail:

________________________________



Name:

________________________________

Phone:

________________________________

Address: _________________________

City: __________ State: ___ Zip: ____

E-mail:

________________________________



On a separate sheet, describe in detail the incident.

On a separate sheet, list all witnesses to the incident.

Has there been any prior history of violence with any of the individuals involved?

[__] Yes    [__] No    [__] Unknown

If yes on a separate sheet please provide the following: Please provide background details (violence, weapon possession, personal problems, drug / alcohol history, etc.). Along with potential warning signs that have been observed / reported (behavior, conduct, stress).

Action Taken:

[__] Manage Internally     [__] Refer to Crisis Assessment Team   [__] No Action Needed

Completed by:

Name:

________________________________

Position:

________________________________

Phone:

________________________________





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