{"id":346,"date":"2024-05-20T14:18:45","date_gmt":"2024-05-20T21:18:45","guid":{"rendered":"https:\/\/kern.org\/occupationalhealthandsafety\/?page_id=346"},"modified":"2024-08-02T21:54:38","modified_gmt":"2024-08-02T21:54:38","slug":"report-a-workplace-violence-issue","status":"publish","type":"page","link":"https:\/\/kern.org\/occupational-health-safety\/report-a-workplace-violence-issue\/","title":{"rendered":"Report a Workplace Violence Incident"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/occupational-health-safety\/wp-json\/wp\/v2\/pages\/346' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_4_30\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_30'>Instagram<\/label><div class='gfield_description' id='gfield_description_4_30'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_30' id='input_4_30' type='text' value='' autocomplete='new-password'\/><\/div><\/li><li id=\"field_4_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Please use this form to report a workplace violence incident.<\/p>\n\n<p>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.<\/p>\n\n\n\n \n\n<\/li><li id=\"field_4_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_5'>\n                            \n                            <span id='input_4_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_4_5_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_4_5_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_6\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'>Contact email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_4_6' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_4_7\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_7'>Contact phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_4_7' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_3' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_3_1_container'><label for='input_4_3_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_3[]' id='input_4_3_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_3_2_container'><label for='input_4_3_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_3[]' id='input_4_3_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_3_3_container'><label for='input_4_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_3[]' id='input_4_3_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_14\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >The date and time of the incident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_14' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_14_1_container'><label for='input_4_14_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_14[]' id='input_4_14_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_14_2_container'><label for='input_4_14_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_14[]' id='input_4_14_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_14_3_container'><label for='input_4_14_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_14[]' id='input_4_14_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_2'>Location of the incident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_4_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_12'>Detailed description of the event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_4_12' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_15\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_15'>Detailed description of any injury, psychological trauma, or stress<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_4_15' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_16'>Who committed the violence?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_4_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>What were the circumstances at the time of the incident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_4_17' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Type 1-4 of Workplace Violence Types<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_28'><li class='gchoice gchoice_4_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='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.'  id='choice_4_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_1' id='label_4_28_1' class='gform-field-label gform-field-label--type-inline'>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.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Type 2: Workplace violence directed at employees by customers, clients, patients, students, inmates, visitors.'  id='choice_4_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_2' id='label_4_28_2' class='gform-field-label gform-field-label--type-inline'>Type 2: Workplace violence directed at employees by customers, clients, patients, students, inmates, visitors.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Type 3: Workplace violence committed against an employee by a present or former employee, supervisor, or manager.'  id='choice_4_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_3' id='label_4_28_3' class='gform-field-label gform-field-label--type-inline'>Type 3: Workplace violence committed against an employee by a present or former employee, supervisor, or manager.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='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.'  id='choice_4_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_4' id='label_4_28_4' class='gform-field-label gform-field-label--type-inline'>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.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_18'>Where did the incident occur?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_4_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What type of workplace violence occurred?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_26'><li class='gchoice gchoice_4_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, \tpunching, slapping, pushing, pulling, scratching, or spitting.'  id='choice_4_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_1' id='label_4_26_1' class='gform-field-label gform-field-label--type-inline'>Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, \tpunching, slapping, pushing, pulling, scratching, or spitting.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object.'  id='choice_4_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_2' id='label_4_26_2' class='gform-field-label gform-field-label--type-inline'>Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Threat of physical force or threat of the use of a weapon or other object.'  id='choice_4_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_3' id='label_4_26_3' class='gform-field-label gform-field-label--type-inline'>Threat of physical force or threat of the use of a weapon or other object.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.'  id='choice_4_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_4' id='label_4_26_4' class='gform-field-label gform-field-label--type-inline'>Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='Animal attack'  id='choice_4_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_5' id='label_4_26_5' class='gform-field-label gform-field-label--type-inline'>Animal attack<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Other'  id='choice_4_26_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_6' id='label_4_26_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_27'>If selected &quot;Other&quot; please describe<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_4_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>If this is an emergency, please call 911 immediately.<\/p>\n\n<p>To report a work-related injury or illness, please click <a href=\"https:\/\/kern.org\/occupationalhealthandsafety\/report-a-work-related-injury-or-illness\/\" target=\"_blank\">HERE<\/a><\/p><\/li><li id=\"field_4_29\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_29'>CAPTCHA<\/label><div id='input_4_29' class='ginput_container ginput_recaptcha' data-sitekey='6LfkbkIqAAAAAF2_-b92kOAOhBYhf8S1utywM2lb'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer 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