720 Preventing Workplace Violence

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Threat Incident Report System

Your company policy may require employees to report all threats or incidents of violence. If you institute such a policy, you must be ready to deal with the situation. The report will be used by the company to assess the safety of the workplace, and to decide upon a plan of action.

Facts you should include in a threat incident report:

Name of the threat-maker and his/her relationship to the company and to the recipient.
Name(s) of victims or potential victims.
When and where the incident occurred.
What happened immediately prior to the incident.
The specific language of the threat.
Any physical conduct that would substantiate an intention to follow through on the threat.
How the threat-maker appeared (physically and emotionally).
Names of others who were directly involved and any actions they took. How did the incident end?
Names of witnesses.
What happened to the threat-maker after the incident.
What happened to the other employees directly involved after the incident.
Names of any supervisory staff involved and how they responded.
What event(s) triggered the incident.
Any history leading up to the incident.
The steps which have been taken to ensure that the threat will not be carried out.
Suggestions for preventing workplace violence in the future.

Sample Threat Incident Report

Sample Incident Report Form

This type of form can be used to report any threatening remark or act of physical violence against a person or property, whether experienced or observed. Individuals may be more forthcoming with information if the form is understood to be voluntary and confidential. The form also needs to identify where it should be sent after completion (for example, workplace violence prevention group or safety committee representative).

Date of Incident	Year			Month			Day of Week
Location of Incident (map and sketch on reverse side):
Name of Victim:					Gender:Male_____ Female_____
Victim Description: ____Employee: Job Title__________________________________ ____Client ____Visitor					Member of Labor Organization?Yes____ No____
Assigned Work Location (if employee)
Supervisor:			Has supervisor been notified?Yes____ No____
Describe the incident.
List any witnesses to the incident (name and phone).
Did the assault involve a firearm? If so, describe.
Did the assault involve another weapon (not a firearm)? If so, describe.
Was the victim injured? If yes, please describe.
Who committed the incident (name, if known)? What is his/her status to the victim:
____Stranger ____Personal Relation ____Client/Patient/Customer		____Co-worker ____Supervisor ____Other				If other, describe:
What was the gender of the person(s) who committed the incident?		____Male ____Female

Please check any risk factors applicable to this incident. Each company should develop and include a list of potential risk factors that may apply in its worksite.

Working with money
Working with drugs
Working in a high-crime area
Working late at night
Poor lighting outside of worksite
Other risk factor: ________________________________________________________
Other risk factor: ________________________________________________________

What steps could be taken to avoid a similar incident in the future?

(To avoid recreating trauma, sound judgment should be exercised in deciding when to request this information.)

Send completed form to:______________________________________

Adapted from: Workplace Violence: Awareness and Prevention for Employers and Employees, Washington State Department of Labor and Industries.

Knowledge Check Choose the best answer for the question.

5-2. Which violence prevention plan report is used by the company to assess the safety of the workplace, and to decide upon a plan of action?