Printable Employee Incident Report Form
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Employee Incident Report |
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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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