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Workplace Violence Incident Report
Workplace Violence Incident Report
Report submitted by:
*
Person filling out this form
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Reporter Status
*
Answer required for "Reporter Status"
Student or former student
BVUSD Employee or former employee
Parent
Reporter First Name
*
Answer required for "Reporter First Name"
Reporter Last Name
*
Answer required for "Reporter Last Name"
Reporter email
Answer required for "Reporter email"
Reporter phone
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Report date:
*
Date incident was reported
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Incident date:
*
Date incident occurred
Answer required for "Incident date:"
Time incident occurred
*
Answer required for "Time incident occurred"
Address/Location of incident
*
Answer required for "Address/Location of incident"
Describe the incident
*
State what was said/done. Use specific language if applicable. Include dates, times, locations, and names of witnesses.
Answer required for "Describe the incident"
Upload any additional information about the incident
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Choose a file
or drag it here.
Assailant Information
Assailant Status
*
Answer required for "Assailant Status"
Student or former student
Employee or former employee
Parent
Stranger
First name of alleged assailant
if known
Answer required for "First name of alleged assailant"
Last Name of alleged assailant
if known
Answer required for "Last Name of alleged assailant"
Nature of Incident
*
(add details below)
Answer required for "Nature of Incident"
1) Stalking
2) Fright, coercion, or duress
3) Destruction of property
4) Hitting, fighting, pushing or shoving
5) Use of object as weapon
6) Use of weapon
7) Verbal harrassment
8) Sexual harrassment
9) Other
Nature of incident details
Reference by category number above to add details. For example 6) knife
Answer required for "Nature of incident details"
Confirmation Email
Confirmation Email
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