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Violent Incident Report

Staff Name*

Answer required for "Staff Name"

Staff Email*

Answer required for "Staff Email"

Staff Phone Number*

Number Required

Date of Incident*

Answer required for "Date of Incident"

Time of Incident*

Answer required for "Time of Incident"

Name of Victim*

Answer required for "Name of Victim"

Name of Perpetrator (Description if name unknown)*

Answer required for "Name of Perpetrator (Description if name unknown)"

Relationship between Victim and Perpetrator (Husband/Wife, Father/Son, coworkers, community member/staff member, etc.) *

Answer required for "Relationship between Victim and Perpetrator (Husband/Wife, Father/Son, coworkers, community member/staff member, etc.) "

Exact location of incident*

Answer required for "Exact location of incident"

Type of Incident*

Answer required for "Type of Incident"

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

Detailed Description of the incident*

Answer required for "Detailed Description of the incident"

Witness 1 (include a way to contact them if you have it)

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Witness 2 (include a way to contact them if you have it)

Answer required for "Witness 2 (include a way to contact them if you have it)"

Supplementary Documentation/Pictures/etc.

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Choose a file or drag it here.

Confirmation Email

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