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Workplace violence reporting form

Workplace violence reporting form

Capture the key facts of workplace incidents with a reporting form that covers what happened, who was involved, and what needs follow-up.

Use this template
or download pdf
Workplace violence reporting form

Capture the key facts of workplace incidents with a reporting form that covers what happened, who was involved, and what needs follow-up.

Use this template
or download pdf

About the Workplace violence reporting form

Workplace violence affects every industry, which is why having a systematic process for reporting incidents is critical to employee safety and compliance. This workplace violence reporting form helps you record the facts, protect your team, and meet internal or legal protocols. Use this template to streamline how you and your team log incidents and take follow-up action.

Key elements of a workplace violence reporting form

Here are the essential components included in the form:

  1. Incident overview: Start with the basics, such as when, where, and what happened. This section sets the context and provides a clear snapshot of the event for internal records or future reference.
  2. Description of the event: This is where you describe the nature of the violence, whether it was physical, verbal, or behavioral. Encourage objective, specific language to avoid ambiguity and keep the report legally sound.
  3. People involved: Document the names, roles, and relationships of both the victim and the perpetrator. This helps you identify patterns and determine next steps, like mediation, investigation, or disciplinary action.
  4. Witness statements: Capture what bystanders saw or heard. These accounts give your report credibility and help reconstruct the incident in greater detail.
  5. Reporting party details: Record who submitted the report and when. This creates accountability and ensures that follow-up action starts from a verified source.

Customizing your workplace violence reporting form

There are different types of workplace violence depending on your industry which is why the form is editable depending on your needs.

To customize it, add custom fields for industry-specific risks, like aggression from patients, clients, or subcontractors. If your team uses internal codes or classifications for types of incidents, build those directly into dropdowns or multiple-choice responses.

You can also adapt the roles and departments listed to reflect your org chart. A form used in a school district, for example, should include roles like administrator, teacher, or support staff.

Another option is to make room for escalation workflows by adding more prompts for follow-up actions or case resolution status. This helps safety teams track repeat incidents and coordinate with HR or legal teams as needed.

Streamline how your team logs incidents

Download this template to document incidents in a way that’s consistent, clear, and built for real workplace situations. With Lumiform’s template, you collect the right details, from timestamps and location to people involved, in a format that’s easy for your team to follow. Whether you’re improving internal protocols or assessing compliance with industry standards, this tool adapts to your workflow.

Related categories

Preview of the template
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Page 1
Incident Details
Date of Incident
Time of Incident
Location of Incident
Describe the Incident
Victim Information
Victim's Name
Victim's Job Title
Victim's Department
Victim's Phone Number
Victim Sustained Injuries?
Perpetrator Information
Perpetrator's Name (if known)
Perpetrator's Relationship to Victim
Perpetrator's Job Title (if applicable)
Was the Perpetrator a Co-Worker?
Was the Perpetrator a Visitor/Customer?
Witness Information
Witness Name
Witness Phone Number
Witness Email
Was the Witness a Co-Worker?
Reporting Information
Reporter's Name
Reporter's Job Title
Reporter's Phone Number
Reporter's Email
Date Reported
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Frequently asked questions

What qualifies as workplace violence?

Workplace violence isn’t limited to physical attacks. It also includes threats, verbal abuse, harassment, intimidation, and disruptive behavior. For example, yelling during a meeting, threatening gestures, or aggressive posturing in shared spaces all count. Even repeated inappropriate jokes or passive-aggressive notes can cross the line, especially when they create a hostile environment.

Who should file the report when an incident happens?

Anyone who witnesses or experiences workplace violence should file the report, not just managers or HR. If you’re unsure whether it’s your role, stay on the side of caution and document it anyway. In many workplaces, reporting is a shared responsibility, and early documentation can prevent escalation or legal complications later.

Should workplace violence reports be anonymous?

Some companies allow anonymous reporting to make employees feel safer speaking up, especially in cases involving supervisors or peers. However, anonymous reports can limit the ability to investigate. A good compromise is offering the option for confidential reporting where identities are protected but can be disclosed if absolutely necessary.

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.