New Jersey Judiciary Incident Report Form
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NEW JERSEY JUDICIARY
Incident Report Form
CHECK ONE:
WORKPLACE VIOLENCE
SECURITY
Fill Out If:
you are a judiciary employee / manager or sheriff’s offi cer.
When:
you witness, are involved in, or are informed of a security incident such as a threat, assault, display or use of a
weapon, escape from custody, theft, disorderly conduct, or disruptive behavior.
Where:
in or around the courthouse, judiciary facility or other location where judicial programs operate, including
parking areas, fi eld locations and during offi cial travel.
File Report:
with immediate supervisor / manager, or Workplace Violence Liaison. THIS IS A CONFIDENTIAL DOCUMENT.
COURT / AGENCY / VICINAGE
DATE OF INCIDENT
TIME OF INCIDENT
DAY OF THE WEEK
AM
PM
STREET ADDRESS
LOCATION / ADDRESS OF INCIDENT:
CITY
COURT HOUSE
ANNEX
COUNTY
PARKING
STATE LEASED /
OTHER COUNTY
OTHER _________________________
LEASED
AREA
OWNED
OWNED
COURT / AGENCY WHERE INCIDENT OCCURRED
TAX COURT
CRIMINAL DIV.
SPECIAL
COURT
SUPREME COURT
CIVIL DIV.
FAMILY DIV.
MUNICIPAL COURT
CIVIL
ADMIN.
APPELLATE DIV.
SHERIFF’S
PROBATION
AOC
SUPERIOR COURT
OTHER ________________________________________
OFFICE
CLERK’S OFFICE
AREA INCIDENT OCCURRED
WAITING
PUBLIC
RESTRICTED
ENTRANCE # _____
SCREENING
ELEVATOR # _____
COURTROOM # _____
AREA # _____
HALLWAY # _____
AREA # _____
POINT # ____
CHAMBERS # _____
CONFERENCE RM # _____
STAIRWELL # _____
OFFICE # _____
OTHER ______________
HOLDING
CELL # _____
TYPE OF INCIDENT
VERBAL
ASSAULT
MAIL THREAT
DAMAGE /
ESCAPE FROM
DISORDERLY
PHONE THREAT
THREAT
VANDALISM
CUSTODY
BOMB THREAT
THEFT
FIRE ALARM
OTHER (be specif c) ________________________________________________
WAS THERE AN EVACUATION?
YES
NO
INDIVIDUALS INVOLVED - Indicate: Subject (S) or Victim/Target (V)
JUDICIARY EMPLOYEE
DEFENDANT
PROBATIONER
JUDGE
PLAINTIFF
WITNESS
SHERIFF’S OFFICER
CURRENT
FORMER
RELATIVE
TROOPER / GUARD
ATTORNEY
OTHER
SPECTATOR
JUROR
PROBATION OFFICIER
(TO BE COMPLETED BY SHERIFF / AOC)
SUBJECT ARRESTED / DETAINED?
SECURITY VULNERABILITY INDICATED?
YES
NO
YES
NO
WEAPON USED, FOUND, DISPLAYED?
IF YES, PLEASE DESCRIBE
YES
NO
BRIEF DESCRIPTION OF INCIDENT
REPORT SUBMITTED BY:
DATE
PHONE NUMBER
PRINT NAME:
SIGNATURE:
x
COUNTY
MUNICIPAL DIVISION MANAGER (IF APPLICABLE)
DATE
PRINT NAME:
SIGNATURE:
PHONE NUMBER
WORKPLACE VIOLENCE LIAISON
DATE
PRINT NAME:
SIGNATURE:
x.
STOP! HAVE ALL QUESTIONS ON THIS FORM BEEN ANSWERED?
YES
NO
Revised: 7/2009
Catalog Number: 10203-English
CONFIDENTIAL DOCUMENT - FOR INTERNAL USE ONLY
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