Langley Schools, Violent Incident Report printable pdf download

INSTRUCTIONS

Langley Schools

1. Complete one per employee involved

VIOLENT INCIDENT REPORT – Part 1

2. Provide the completed report to your

Administrator/Supervisor

Background Information:

3. Administrator/Supervisor to follow

investigation instruction on the

School/Site:

Specific Location:

reverse side.

4. If you have been injured, please

complete an Employee

Date & Time of Incident

Date & Time Employee Reported

Injury/Accident Report Form.

Incident

5. Incidents to be reported as soon as

possible

Name of Employee Involved in Incident

Work Phone #

Position

Name of Administrator / Supervisor

Work Phone#

Name of witnesses: 1:

Nature of injury or illness: (include body area/part affected; left vs. right; psychological; etc.)

•

Did the employee see a physician?

Yes

No If yes, when?

Did the employee seek First Aid?

Yes

No (If no, remind the employee they should)

•

Was the employee absent from work as a result of the incident?

Yes

•

If yes, provide dates:

If yes, please fill out an Employee Injury/Accident Form and file a Teleclaim, 1-888-WORKERS

Description of the Violent Incident: (Attach supporting documents as required. Include sequence of events, sketch, equipment, etc.)

PERSON INVOLVED

Parent

Other:

IF KNOWN: Name:

Student, Grade ______

Ministry Designated Student

ONLY COMPLETE IF PERSON IS UNKNOWN:

Male

Estimate Age:

Height:

Hair Colour:

Hair Length:

Facial Hair:

Female

Weight:

Complexion:

Glasses?

Other identifying features (clothing, tattoos, scars, birth marks, accent, etc)

VEHICLE INVOLVED (if applicable): Make:

Model:

Year:

Licence #

Colour:

Condition / Identifying features:

Signature (employee):

Print Name

Date

DISTRIBUTION KEY:

School Records

Assistant Superintendent

Director H&S

Personal information on this form is collected by School District #35 (Langley) for the purpose of investigation, correction and prevention of violent incidents in the

workplace and for the administration of the Health and Safety Program. Personal information on this form is collected and will be protected in accordance with the

freedom of Information and Protection of Privacy Act.

For further information, please contact the Director – Health and Safety at School District #35 (Langley), 4875 –222 Street, Langley, BC V3A 3Z7