New Submission

Appendix A
This internal, confidential form is to be completed by the victim and submitted to the District employee(s) investigating the incidents related to workplace violence. Please note this is not the Violent Incident Log. The Violent Incident Log must separately be completed for every instance of workplace violence and is a publicly available document.
Submitter First Name:*field type single line
(Ensure correct First Name)
Input blocked. Maximum character limit of 4000 characters reached.
Submitter Last Name:*field type single line
(Ensure correct Last Name)
Input blocked. Maximum character limit of 4000 characters reached.
District \ Site:*field type drop-down
(Ensure correct correct Dist \ Site)
Date:*field type date
Job Title:*field type single line
.
Input blocked. Maximum character limit of 4000 characters reached.
Email:field type email
(Ensure correct Email address.)
Phone:field type single line
(Ensure correct Phone Number)
Input blocked. Maximum character limit of 4000 characters reached.
Year:*field type drop-down
(Ensure correct year range)
FirstAppPSfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
FirstAppEmail:field type email
SecondAppBDfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
SecondAppEmailfield type email
EndUserfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date Of Incident:*field type date
Time Of Incident:*field type time
Address / Location of Incident:field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Supervisor:field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Classification / Where Incident Occurred:field type multi line
(Please Describe whether office, classroom, playground, parking lot or other location)

Individuals Involved in or Witnessing the Incident:

Victim(s):
×
- Victim First Name:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Victim Last Name:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Title:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Immediate Supervisor:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Supervisor Contacted?:field type radio button
  Supervisor Contacted?:YesNo
Add
Assailant(s):
×
- Assailant First Name:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Assailant Last Name:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Title:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Immediate Supervisor:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Supervisor Contacted?:field type radio button
  Supervisor Contacted?:YesNo
Add
Witness(s):
×
- Witness First Name:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Witness Last Name:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Title:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Immediate Supervisor:field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Supervisor Contacted?:field type radio button
  Supervisor Contacted?:YesNo
- Contact Information or Parent Contact if Student Witness:field type multi line
Add

Assailant Relationship to Employee:

Please select a relationship:field type checkbox
Please select a relationship:Co-workerFormer EmployeeVendor/ContractorStudentParentVisitor/VolunteerFamily/acquaintance of StudentFamily/acquaintance of EmployeeOther (Specify Below)
Other:field type single line
(Specify i.e. family member, current of former partner, stranger)
Input blocked. Maximum character limit of 4000 characters reached.

Detailed Description of Incident:

Please enter description of incident below.field type multi line

Nature of Incident:

Nature of Incident (Check all that apply):field type checkbox
Nature of Incident (Check all that apply):StalkingEngaging in actions intended to frighten, coerce, or induce duressDestruction of PropertySexual AssaultVerbal HarassmentRobberyThreats of Physical Violence/Threats with WeaponArsonBomb ThreatLaw Enforcement ContactedOther (Specify Below)
Other:field type single line
(Specify Other Nature of Incident)
Input blocked. Maximum character limit of 4000 characters reached.
Physical Assault (Check all that apply):field type checkbox
Physical Assault (Check all that apply):HitFightPushGrabKickScratchBiteSlapShovePunch
Armed Assault (Please Select):field type radio button
Armed Assault (Please Select):YesNo
.field type single line
Use of object as a weapon (Specify)
Input blocked. Maximum character limit of 4000 characters reached.
.field type single line
Use of weapon such as gun, knife, etc. (Specify)
Input blocked. Maximum character limit of 4000 characters reached.
Animal Attack (Please Select):field type radio button
Animal Attack (Please Select):YesNo
.field type single line
(Specify Animal Attack)
Input blocked. Maximum character limit of 4000 characters reached.

Threats of Violence - How was the threat of violence communicated to the victim? (Check one or more)

Communicated directly to victim:field type checkbox
Communicated directly to victim:VerbalLetterEmail
Communicated to another person:field type checkbox
Communicated to another person:VerbalLetterEmail
Other (Specify):field type single line
Input blocked. Maximum character limit of 4000 characters reached.

Victim Injury:

(Check all that apply):field type checkbox
(Check all that apply):Physical Injury - No medical care requiredPhysical Injury - Medical care required
SCROLL TO THE BOTTOM OF THE PAGE TO SUBMIT.

Principal \ Supervisor Section:

Initial Response or Follow-up Activity:field type multi line
(Include detailed description, including whether low enforcement or security was called and what actions were taken to protect employees from continuing threat.)
Principal \ Supervisor Signature:field type signature
Date:field type date

Business Department Section:

Business Department Comments:field type multi line
Business Department Signature:field type signature
Date:field type date

Definition of Incidents:

Assault
The intentional use of physical injury, (impairment of physical condition or substantial pain) to another person, with or without a weapon or dangerous instrument.
Criminal Mischief
Intentional or reckless damaging of the property of another without permission.
Disorderly Conduct
Intentionally causing public inconvenience, annoyance or alarm or recklessly creating a risk thereof by fighting (without injury) or violent, numinous (mysterious) or threatening behavior or making unreasonable noise, shouting abuse, misbehaving, disturbing as assembly or meeting of persons or creating hazardous conditions by an act which serves no legitimate purpose.
Harassment
Intentionally striking, shoving or kicking another or subjecting another person to physical contact, or threatening to do the same (without physical injury). Also, using abusive or obscene language or following a person in/about a public place, or engaging in a course of conduct which alarms or seriously annoys another person.
Larceny
Wrongful taking, depriving or withholding property from another (no force involved). Victim may or may not be present.
Menacing
Intentionally places or attempts to place another person in fear of imminent serious physical injury.
Reckless Endangerment
Subjecting individuals to danger by recklessly engaging in conduct which creates substantial risk of serious physical injury.
Robbery
Forcible stealing of another's property by use of threat or immediate physical force. Victim is present and aware of theft.
Sex Offense
Public Lewdness: Exposure of sexual organs to others.
Sexual Abuse: Subjecting another to sexual contact without consent.
Sodomy: Adeviat sexual act committed as in rape.
Rape: Sexual intercourse without consent.

Columbia Elementary School District Workplace Violence Reporting Form

Individuals Involved in or Witnessing the Incident:

Victim(s):

Assailant(s):

Witness(s):

Assailant Relationship to Employee:

Detailed Description of Incident:

Nature of Incident:

Threats of Violence - How was the threat of violence communicated to the victim? (Check one or more)

Victim Injury:

Definition of Incidents: