Homak Intake
Workplace Violence Log
Store 34994
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Name *
Job title *
Date completed *
Date of incident *
Time of incident *
Location of incident *
Classify the nature of the location (e.g., workplace, parking lot, area outside of workplace, or other area) *
Workplace violence type *
Select…
Type 1 — Violence committed by a person who has no legitimate business at the workplace.
Type 2 — Violence committed by a customer, client, patient, student, inmate or visitor.
Type 3 — Violence committed by a present or former employee, supervisor or manager.
Type 4 — Violence committed by a nonworker with a personal relationship with the employee.
Classify the type of person committing the violence (e.g., customer/client or their family member, coworker, spouse, parent or other family member or stranger with criminal intent) *
Type of incident (check all that apply) *
Physical attack without a weapon (e.g., punching, kicking, spitting, biting, choking, grabbing or pushing).
Attack with a weapon or other object (e.g., firearm or knife).
Threat of physical force or use of weapon or other object.
Sexual assault or threat of sexual assault (e.g., rape, attempted rape, or physical display).
Animal attack.
Other
If "Other", describe
Describe the incident in detail — include whether the employee was completing usual job duties, working in poorly lit areas, rushed, working during low staffing, isolated or alone, unable to get help, in a community setting, or in a new/unfamiliar location *
Were security or law enforcement contacted? *
Select…
Yes
No
If contacted, describe their response
Actions taken to protect employees from a continuing threat of violence or other hazards identified *
Other consequences of this incident, if any
Submit
