Employee Incident Report
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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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