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Workplace violence incident report form

Workplace violence incident report form

This customizable template gives you a clear and organized way to document workplace violence incidents. Use it to capture key details and take action.

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Workplace violence incident report form

This customizable template gives you a clear and organized way to document workplace violence incidents. Use it to capture key details and take action.

Use this template with Lumiform

  • Customize this template or build your own
  • Fill out templates via mobile app
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

Document workplace violence incidents thoroughly with this detailed reporting form designed to capture critical information for proper investigation and prevention. When verbal threats or physical assaults occur in your workplace, having a standardized reporting process ensures nothing is overlooked.

The US Bureau of Labor Statistics reports that non-fatal workplace violence requiring days away from work, job restriction, or transfer (DART) happens at around 2.9 cases per 10,000 full-time employees, showing the importance of proper documentation. Track incidents systematically with this form, whether it’s harassment between coworkers or aggressive behavior from customers.

Related categories

  • Health and safety management templates
  • Risk management and compliance templates
  • General templates
  • Professional services templates
  • Incident management templates
  • Workplace safety templates
Preview of the template
Page 1
Incident Details
Date of Incident
Time of Incident
Type of Incident
Provide a detailed description of the incident, including any actions taken and injuries sustained.
Victim Information
Name of Victim
Job Title of Victim
Department of Victim
Describe any physical or emotional injuries sustained by the victim.
Medical Treatment Provided
Perpetrator Information
Name of Perpetrator (if known)
Relationship to Victim
Perpetrator's Actions
Weapons Involved
Reporting Information
Name of Person Reporting Incident
Job Title of Person Reporting
Date Reported
Time Reported
Describe any immediate actions taken in response to the incident.
Law Enforcement Notified

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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

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Frequently asked questions

What should I include in the detailed description of the incident?

Focus on observable facts rather than opinions or assumptions. Note the sequence of events, exact words used during verbal threats, specific physical actions, witnesses present, and the context in which the incident occurred. Include environmental factors that may have contributed and document any evidence available (security footage, emails, texts). Be thorough but stick to what you personally witnessed or know to be true.

When should I notify law enforcement about a workplace violence incident?

You should notify law enforcement immediately for incidents involving weapons, physical assault resulting in injury, explicit threats of serious harm, stalking behavior, or any situation where you believe someone is in imminent danger. For less severe incidents, follow your company’s escalation policy. Remember that employees always have the right to contact police if they feel unsafe, regardless of company reporting procedures.

How can I support a colleague who has been the victim of workplace violence?

Offer immediate emotional support without judgment and ensure they receive any needed medical attention. Respect their privacy while encouraging them to complete the incident report. Connect them with available resources like your Employee Assistance Program or counseling services. Check in periodically in the days following the incident, and help create a safety plan if they’re concerned about future interactions with the perpetrator.

What happens after I submit this workplace violence incident report form?

After submission, the report typically goes to designated personnel (HR, security, or management) who will review the information and initiate an investigation. They may interview witnesses, gather evidence, and determine appropriate actions. You should receive acknowledgment of your report and may be contacted for additional information. The organization should also implement immediate protective measures if there’s ongoing risk.


This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
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