Form 1 Worker'S Statement Of Incident - School District 61
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1
2Form 1
INSTRUCTIONS
Worker’s Statement of Incident
Complete Form 1 prior to any other form.
*This form is N/A for worker to worker incidents
Completed by Worker(s) involved.
Provide the completed report to your P/VP
School Site:
Specific Location:
or Supervisor.
P/VP or Supervisor to follow investigation
Date & Time of Incident:
Date & Time Worker Reported
process.
Incident:
If you have been injured, please see First Aid
AM
Attendant.
AM
PM
Incidents to be reported as soon as possible.
PM
Name of Worker Involved in Incident:
Work Phone #
Position
Name of P/VP or Supervisor:
Work Phone #
Name of Witnesses:
1.
2.
3.
In your best professional judgment, this incident involving violence can be best categorized as:
Verbal abuse
Verbal threat
Written threat
Threatening Gestures
Physical assault
Weapon involved
yes
no If yes, specify: ___________________________________________________
Parent
Other __________________
Aggressor’s Name (if known):
Student
______________________________________
DOB: ___________________
Gr: ___
Nature of Injury:
(Include body area/part affected; left, right; psychological, etc.)
Yes
No
Did you seek First Aid?
Yes
No
Did you see a physician?
(If yes, complete Form 6A)
If yes, when? ___________________________(Dates)
Were you absent from work? Yes (
No
If yes, complete Form 6A)
If yes, when? ___________________________ (Dates)
Description of Violent Incident:
(Attach supporting documents as required. Inc. sequence of events, sketch, equipment, etc.)
Completed Form 2 Yes No
No Further Action Required
Next Steps/Action Taken:
P/VP or Supervisor’s Signature: _______________ Date: __________ Worker’s Signature: ____________________ Date: _____________
Copies to:
Associate Superintendent (via email)
P/VP or Supervisor (redacted version to be shared with JOHS Committee)
HR (cmerner@sd61.bc.ca)
District Behavioral Consultant (dmarchant@sd61.bc.ca)
Worker (redacted)
File this completed form, in a binder, in a secure location in the administrator’s office.
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