Nc Dps Workplace Violence Incident Report
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1
2DEPARTMENT OF PUBLIC SAFETY
Print Form
WORKPLACE VIOLENCE INCIDENT REPORT
To be completed by the individual investigating the incident. Return completed for within 7 days following incident to the
DPS Human Resource Office, Workplace Violence Coordinator. Attach victim/witness statements to this form.
Date:
Report submitted by:
Title:
Telephone:
AM
PM
Time:
Date of incident:
Address/Location of Incident:
Individuals involved in the incident (use additional sheet(s) if necessary):
Name:
Name:
Victim or
Assailant
Victim or
Assailant
Title:
Title:
Division:
Division:
Phone:
Phone:
Immediate Supervisor:
Immediate Supervisor:
Assailant Relationship to Employee
Co-worker
Customer/Client
Supervisor
Person In Custody
Former Employee
Stranger
Spouse/Family Member
Other
Reason for Incident: (if known, check all that apply):
Conflict with co-worker(s)/former co-worker
Alcohol/Drugs in the workplace
Conflict with supervisor
Mental health problems
Family/domestic dispute
Reduction in force
Receiving a poor performance appraisal
Demotion
Receiving disciplinary action
Dismissal
Racial Tension
Resisting arrest
Other (specify)
Form HR 549 Workplace Violence Incident Report
Page 1 of 2
Form last revised March 2014
NC Department of Public Safety
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