Full Text
Cortland County Workplace Violence Incident Report Date of incident: / / Name of individual completing report: Job title: Department: Today’s date: / / Time of incident: AM PM Incident involving: Department County Specific Person(s) Name of alleged victim(s): Job title (if applicable)/or other identifier: Describe the incident (attach police report if If incident was a threat, how was the threat made? (Check all that apply) In person On County property Written Social Media Other: Home Visit Telephone Witness(es): Job title (if applicable)/or other identifier: Address/location where incident took place: Name of alleged perpetrator(s): Job title (if applicable)/relationship to agency: Phone number: ( ) - Physical Description: Male Female Height: Weight: DOB or approximate Hair Eye color: Complete this section if incident involves individual(s) known to you Complete this section if incident involves individual(s) unknown to you Page 1 of 3 ---PAGE BREAK--- Description of voice (Check all that apply): Male Female Old Middle-age Young Calm/Quiet Crying Shouting Angry Foul-abusive language Aggressive/interruptive Speech impairment, Other, Weapon(s), including objects used as Nature and extent of injuries arising from the incident: Has this happened before? (If so, give details): Is there something that exacerbated the situation?(If yes, explain): What was the immediate action taken? Is there other known history of the person who cause the incident? Yes No Name of Officer: Time: AM PM Police Notified: Agency: Date: Other actions taken: Unknown individual(s) continued Page 2 of 3 ---PAGE BREAK--- By phone By email In person - Email: / Time notified: AM PM By phone Be email In person Dept. Head notified: Contact ( ) Date of notification: Safety Director notified: Date of notification: / / Time notified: AM PM ADDITIONAL INFORMATION (Attach additional sheets if **Your name will NOT be used on the Workplace Violence annual reports** SUBMIT ALL DOCUMENTS VIA WEB PORTAL AT: Page 3 of 3