Sample

Assault Incident Reporting Form

Put a procedure in place for reporting incidents internally and to the police. A form would include:

Date _________________________

Time _________________________

Location of incident ______________________________

Description of incident ____________________________

Who was directly involved ____________________________

Name, title, address, phone number ____________________________

__________________________________________________________


Relationship between people involved (spouse, ex co-worker, supervisor, etc.)

__________________________________________________________

Who witnessed the event ____________________________________


Witnesses’ experience of the event (what they saw; what was said by whom, etc.) _____________________________________________________

__________________________________________________________

__________________________________________________________