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Holy Trinity Roman Catholic

502 Sixth Avenue North East

Moose Jaw, SK S6H 4P8

Violent Incident Report Form

If you require more space, please provide details on a separate page and attach to this form.

1. Information about the Employee victim

Name: _______________________________________

Position: _______________________________________

Workplace: _______________________________________

2. Information about the incident

Date of incident: ________________ Time of incident: ______________

Location in workplace where incident occurred: _______________________

Type of incident: Threat _______ Physical Assault _______ Other ______

Please describe the incident:

______________________________________________________________

Did the perpetrator threaten to use a weapon? YES NO

Was a weapon used against you? YES NO

Please describe:

______________________________________________________________

3. Information about any injury or property damage/loss sustained

Were you injured during the incident? YES NO

Did you suffer any property damage/loss? YES NO

Please describe the injury or damage/loss and attach a copy of the Injury Report form:

______________________________________________________________

Did you require medical attention? YES NO

If so, please describe:

______________________________________________________________

4. Information about the perpetrator:

Do you know the identity of the perpetrator? YES NO

If yes, name the perpetrator: _________________________________________

If you do not know the name, please provide details that may assist in identification:

______________________________________________________________

5. Information about witnesses to the incident

Names of witnesses to incident, if any: ______________________________

______________________________________________________________

Please provide a copy of this report to your principal/supervisor.

_________________________________________ __________________

Signature Date