Nc Dps Workplace Violence Incident Report Page 2
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1
2Type of Incident (Check one or more)
Threat
Communicated directly to victim
Verbal
Mail
Note
Email
Communicated to another person
Verbal
Mail
Note
Email
Other (specify)
Intimidation
Stalking
Engaging in actions intended to frighten, coerce, or induce duress
Other (specify)
Physical Attack
Hitting, fighting, pushing, or shoving
Use of object as weapon (specify)
Use of weapon such as gun, knife, etc. (specify)
Other (specify)
Check if victim sustained physical or traumatic/emotional injury in any of the following categories:
Physical injury
Trauma/Emotional injury
Medical care required
Death
Initial Response: (Check all that apply)
Situation defused
Medical Director notified
Security called
Member Assistance Team notified
Workplace Violence Coordinator notified
Employee Assistance Program referral
Law Enforcement notified
If Yes, Name of Agency and Report Number:
Other (specify)
Follow-up Response: (Check all that apply)
Medical treatment provided to victim
Victim referred to counseling
Medical treatment provided to assailant
Assailant referred to counseling
Workers' Compensation claim filed
Form HR 549 Workplace Violence Incident Report
Page 2 of 2
Form last revised March 2014
NC Department of Public Safety
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