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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.

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  • Get reports and analyse your data
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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 with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

This workplace violence reporting form helps organizations document, track, and respond to incidents of violence in the workplace. It captures critical incident details, victim and perpetrator information, witness statements, and reporting data for proper investigation and follow-up.

Based on US Bureau of Labor Statistics data, over 20,050 workers in the private industry experienced trauma from nonfatal workplace violence in a year, requiring days away from work. When an incident occurs, having a standardized reporting system ensures you don’t miss important information, helping you protect your employees while meeting compliance requirements.

Related categories

Preview of the template
Entity
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 should I do immediately after receiving a completed workplace violence reporting form?

After receiving a completed form, prioritize employee safety first. Check if medical attention is needed for the victim. Secure the incident area if necessary and contact appropriate authorities if the situation warrants. Then begin your internal investigation process while maintaining confidentiality and providing support resources to affected employees. Document all actions taken in response.

How can I encourage employees to use the workplace violence reporting form?

Create a culture where reporting is valued by clearly communicating your zero-tolerance policy for workplace violence. Ensure confidentiality and protection from retaliation for those who report incidents. Make the form easily accessible in multiple locations and formats. Provide regular training on recognizing warning signs and the importance of reporting, emphasizing that completed forms help create a safer workplace for everyone.

What information from the workplace violence reporting form should be shared with other employees?

Share only what’s necessary to maintain workplace safety while protecting the privacy of those involved. You might communicate general information about increased security measures or remind staff about violence prevention policies. Never share personal details about victims or perpetrators. Consult legal counsel before making any announcements to ensure you’re balancing transparency with confidentiality requirements and legal obligations.

When should law enforcement be contacted after receiving a workplace violence reporting form?

Contact law enforcement immediately if the incident involves weapons, physical assault, explicit threats, stalking, or if anyone’s safety is at immediate risk. Also report incidents involving restraining order violations, property damage, or when the perpetrator remains at large and poses a threat. Even for less severe incidents, consider consulting with police to create documentation, especially if you suspect the situation could escalate.

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.