Report a Workplace Violence Incident | Occupational Health and Safety

Please use this form to report a workplace violence incident.

The fields for Name, Contact Email, and Contact Phone are optional. If you wish to submit an anonymous report, please leave these fields blank. No employee will be subjected to termination, retaliation, or discrimination for making complaints, instituting proceedings, testifying with regards to employee workplace violence, or reporting a workplace violence incident.

Name

First Last

Contact email

Contact phone

Today's Date*

The date and time of the incident*

Location of the incident*

Detailed description of the event*

Detailed description of any injury, psychological trauma, or stress*

Who committed the violence?*

What were the circumstances at the time of the incident?*

Type 1-4 of Workplace Violence Types*

Type 1: Workplace violence committed by a person who has no legitimate business at the worksite and includes violent acts by anyone who enters the workplace or approaches workers with the intent to commit a crime.
Type 2: Workplace violence directed at employees by customers, clients, patients, students, inmates, visitors.
Type 3: Workplace violence committed against an employee by a present or former employee, supervisor, or manager.
Type 4: Workplace violence committed in the workplace by a person who does no work there but has or is known to have had a personal relationship with an employee.

Where did the incident occur?*

What type of workplace violence occurred?*

Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting.
Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object.
Threat of physical force or threat of the use of a weapon or other object.
Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.
Animal attack
Other