Workplace Violence Incident Report Form This form must be used to document any reportable workplace violence incident. For any Level incident, ‘an employee must report the incident to the Department Head within 48 hours of the occurrence, For all Level Il eval ll incidents, this completed form mus be submitted immediately. The. is fespons {for forwarding this form to the Compiroler or the Town Supervisor within the same timeframes. Victim's Name Job Tile ‘Department / Location Date and Time of Incident Location of incident Name /Job Title of Individual Completing Report Date incident Report Completed Dale Incident Report Received by Comptroller ‘The following are examples of Level types of workplace violence incidents. + Harassment © Obscene language * Verbal abuse Intimidation + Shouting + Obscene gestures © Bullying # Folee statements ‘The following are examples of Level II types of workplace violence incidents, + Threatening with Verbal threats of © Obscene or * Being followed or stalked ‘an object assault threatening cals ‘The following actions are examples of Level Ill types of workplace violence incidents. + Pushing + Striking with an Sexual Assaut +: Homicide + Grabbing Object = expend + Shooting Describe each ineident separately, including dates, times and locations. If you cannot remember exact dates, times cor locations, please provide approximations. Use additional pages if necessary, FORM-T Page 1 of 2List any individuals who may have witnessed this incident ‘Witness Name Witness Job Tile Witness Work Phone Number ‘Assailant / Perpetrator Name ‘Address Town State Member of the Public Employee's Spouse Employee's Significant Other Employee's Supervisor Former employee E : Coworker fH (Other (Specify) +1 attest that the information | have provided isa true and accurate description of my complaint and that | have not wilfully o deliberately made false statements. | understand that The Town of Niskayuna prohibits any individual from retaliating against me for fling a complaint and that | am to notify my Deparment Head, the Comptroller or the Town Supervisor il believe that am a victim of retaliation] EMPLOYEE SIGNATURE DATE DEPARTMENT HEAD SIGNATURE DATE COMPTROLLER OR DESIGNEE DATE FORWT Page 2 of 2