State of California Department of Insurance

WORKPLACE VIOLENCE PREVENTION INCIDENT REPORT FORM

HRM 087 (New form)

Workplace Violence Prevention Incident Report Form

Part I through Part V should be completed by the appropriate supervisor based on information provided by the employee(s) involved in the incident. Part VI should be completed by the Departmentís Health & Safety Officer following the investigation of the reported incident.

PART I - NATURE OF INCIDENT - (check all that apply)

Section A

Threat Verbal Written

Electronic Physical with Injury Physical without Injury

Harassment Behavioral Observation Information Only

Other (Please Describe)

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Section B

Date of incident: __________________ Approximate Time: _______________ a.m./p.m.

Description of observation, threat, incident, or activity. Continue on separate sheet of paper if necessary.

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PART II - INCIDENT DIRECTED AT:

Person(s): ____________________________________________________________________________________________

Place: _______________________________________________________________________________________________

Structure: ____________________________________________________________________________________________

PART III - INCIDENT INITIATED BY:

Person(s): ____________________________________________________________________________________________

  Male Female Employee Classification:_________________________________________________________________________________________

Worksite:________________________________________________________________________________________________________________________________________________________________________________________________

PART IV - TYPE/LOCATION INCIDENT OCCURRED

Section A

Type of Contact:

  In person Telephone Mail Observation Recording

  Electronic Mail Fax Other ______________________________________________________________

Was the employee alone? Yes No

Section B

Location of Incident:

  Worksite Employee's Residence Other __________________________________________________

Section C

Address/Location where incident occurred:

____________________________________________________________________________________________________

Street City State Zip Code

Section D

What type of incident was it? Type I Type II Type III

Were any threats made before the incident occurred? Yes No

Did the employee(s) ever report to the department that he/she was threatened, harassed, or suspicious that the attacker may become violent? Yes No

Was the perpetrator a stranger, client/patient, co-worker, or otherwise familiar person?__________________________________________________________________________________________________________________________________________________________________________________________________

Was a weapon used? Yes No

If yes, what type of weapon? ____________________________________________________________________________________________________

Section E

Were there injuries? Yes No

If yes, who was injured?

Name:_________________________________Phone:________________________________________________________

Injury Description:_____________________________________________________________________________________

Name:_________________________________Phone:________________________________________________________

Injury Description:_____________________________________________________________________________________

Name:_________________________________Phone:________________________________________________________

Injury Description:____________________________________________________________________________________

Witnesses(s) to the incident:

Name: ____________________________ Phone Number: ____________________________________________________

Address:_____________________________________________________________________________________________

Street City State Zip Code

Name: ____________________________ Phone Number: ___________________________________________________

Address:____________________________________________________________________________________________ Street City State Zip Code

Name: ____________________________ Phone Number: ____________________________________________________

Address:_____________________________________________________________________________________________

Street City State Zip Code

PART V - ACTION TAKEN-REPORTING SUPERVISOR

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Law enforcement or other outside agencies contacted? Yes No

Agency Name:_____________________________________________________________________________________

Case Number If Applicable:__________________________________________________________________________

Were Employee Assistance Program services offered? Yes No

If yes, when? _____________________________________________________________________________________

Completed By: ___________________________ Date: ________________________________________________

Title: ___________________________________ Location: ____________________________________________

(Supervisors should submit this form to the Departmentís Health and Safety Officer within five (5) working days of the reported incident to: 300 Capitol Mall, Suite #1300 Sacramento, CA 95814).

PART VI Ė RECOMMENDED ACTION: (To be completed by the Health & Safety Officer)

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Completed By: ______________________________ Date:___________________________________________________

Rev. 01/03