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Workplace Violence Incident Report
Workplace Violence Incident Report
Report submitted by:
*
Person filling out this form
Answer Required
Reporter Status
*
Answer Required
Student or former student
BVUSD Employee or former employee
Parent
Reporter First Name
*
Answer Required
Reporter Last Name
*
Answer Required
Reporter email
Answer Required
Reporter phone
Number Required
Report date:
*
Date incident was reported
Answer Required
Incident date:
*
Date incident occurred
Answer Required
Time incident occurred
*
Answer Required
Address/Location of incident
*
Answer Required
Describe the incident
*
State what was said/done. Use specific language if applicable. Include dates, times, locations, and names of witnesses.
Answer Required
Upload any additional information about the incident
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Choose a file
or drag it here.
Assailant Information
Assailant Status
*
Answer Required
Student or former student
Employee or former employee
Parent
Stranger
First name of alleged assailant
if known
Answer Required
Last Name of alleged assailant
if known
Answer Required
Nature of Incident
*
(add details below)
Answer Required
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
Confirmation Email
Confirmation Email
Email Required
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