Employee Incident Report printable pdf download

Employee Incident Report

Date: ____/____/_______

Name: __________________________________ Phone: _______________________________

Address: _______________________________ City:_______________ State:_____ Zip:_______

E-mail: _________________________________

Individuals that were involved in the incident:

Name: __________________________________ Phone: _________________________

•

Address: ________________________ City:_______________ State:_____ Zip:_______

E-mail: _________________________________

Name: __________________________________ Phone: _________________________

•

Address: ________________________ City:_______________ State:_____ Zip:_______

E-mail: _________________________________

On a separate sheet, describe in detail the incident.

On a separate sheet, list all witnesses to the incident.

Has there been any prior history of violence with any of the individuals involved?

[__] Yes

[__] No

[__] Unknown

If yes on a separate sheet please provide the following: Please provide background details (violence,

weapon possession, personal problems, drug / alcohol history, etc.). Along with potential warning signs

that have been observed / reported (behavior, conduct, stress).

Action Taken:

[__] Manage Internally [__] Refer to Crisis Assessment Team

[__] No Action Needed

Completed by:

Name: ____________________________ Position: _______________________

Phone: ____________________________

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Employee Incident Report