Spreadsheet: 0332fb62-c405-4f80-8c27-b17e6aa56607
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | CDHS WORKPLACE VIOLENCE | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8
 |  |  |  | INCIDENT REPORT
 |  |  |  | Please check (X) all boxes that apply.  Add narrative as necessary.
 | Contact: |  | Consultation |  |  |  | Incident Report
 | Reported to: |  | North Central District Risk Manager
 |  |  | Southern District Risk Manager
 |  |  | Western District Risk Manager
 |  |  | Other
 |  |  |  | Please Identify
 | Reported by:
 | Phone Number: |  |  |  | Fax:
 | Date Reported: |  |  |  | Date of Incident:
 | Agency: |  |  |  | Time of Incident:
 | Facility: |  |  |  | AM
 | Location: |  |  |  | PM
 | Incident Reported to: |  | Supervisor |  |  |  | Agency Director
 |  |  | On-Site Security |  |  |  | Police Authority
 |  |  | Other
 |  |  |  | Please Identify
 | Did Injury Result?: |  | Yes |  | No
 | IOJ Filed?: |  | Yes |  | No
 | Medical Treatment?: |  | Yes |  | No
 | Lost Time?: |  | Yes |  | No
 | Fatality?: |  | Yes |  | No
 | Details of Property
 | Damage (if any):
 | Victim(s)
 | Job Classification:
 | Perpetrator(s)
 | Job Classification:
 |  |  |  | Collect witness statements and file.  Do not submit to District Risk Manager unless requested.
 | Alleged: |  | Employee to Employee |  |  |  | Visitor to Employee
 |  |  | Employee to Supervisor |  |  |  | Employee to Visitor
 |  |  | Supervisor to Employee |  |  |  | Other
 |  |  | Client to Employee |  |  |  | Please Identify
 |  |  | Employee to Client
 |  |  |  | Incident |  | Incident
 |  |  |  | attempted/threatened |  | occurred
Type of Incident: |  | Grabbed
(Check all that apply)
 |  | Pushed
 |  | Slapped
 |  | Kicked
 |  | Scratched
 |  | Hit with fist
 |  | Hit with object
 |  | [NAME]
 |  | [NAME]
 |  | Shot
 |  | Assaulted with
 |  | other weapon
 |  | Sexually Assaulted
 |  | Animal attack
 |  | Robbery
 |  | Vandalism
 |  | (employee property)
 |  | Vandalism
 |  | (employer property)
 |  | Bomb
 |  | [NAME]
Type of Incident: |  |  |  |  |  | Incident
(continued) |  |  |  |  |  | occurred
 |  | Verbally harassed
 |  | Verbally threatened
 |  | Threatened with weapon
 | If not identified previously, what type of
 | weapon was used and how was it obtained?
 | Incident Description:
 | Investigation: |  | In Progress
 |  |  | Administrative Leave Pending Outcome
 |  |  | Completed
 | Investigator: |  | Supervisor
 |  |  |  |  | Please Identify
 |  |  | District Risk Manager
 |  |  | Agency Investigator
 |  |  |  |  | Please Identify
 |  |  | Other
 |  |  |  |  | Please Identify
 | Action Taken: |  | Corrective Action |  |  |  | EAP
 | (Check all that apply)
 |  |  | Discipline |  |  |  | Mediation
 |  |  | Termination |  |  |  | Conflict Resolution
 |  |  | Temporary Reassignment |  |  |  | Criminal Charges
 |  |  | [NAME] |  |  |  | [NAME]
 |  |  | Other
 |  |  |  | Please Identify
 | Post-Incident: | Was a critical incident debriefing provided to affected staff?
 |  |  |  | Yes |  | No |  | N/A
 |  | Was post-incident counseling provided to affected staff?
 |  |  |  | Yes |  | No
Thank you for completing this report.  Please email this report upon its completion to your District
Manager of Benefits and Risk Management.