Form 1 Worker’s Statement of Incident *This form is N/A for worker to worker incidents School Specific Site: Location: Date & Date & Time Time of Worker Incident: Reported Incident: Name of Worker Work Phone Position: Involved in Number: Incident: Name of P/VP or Work Phone Supervisor Number: Name of 1. 2. 3. Witnesses: In your best professional judgment, this incident involving violence can be best categorized as: Verbal Verbal Threat Written Threatening Physical Assault abuse Threat Gestures Weapon If yes, Involved: specify: Aggressor’s Name (if known): Parent Other Student DOB: Grade: Nature of Injury: (include body area/part affected: left, psychological etc. Did you seek Aid? Did you see a If yes, complete form If yes, when? Provide physician? 6A dates: Were you absent from If yes, complete form If yes, when? Provide work? 6A dates: Description of Violent Incident: (Attach supporting documents as required. Inc. sequence of events, sketch, equipment, etc). Next Steps/Action Completed Form 2 No Further Action Required Taken: P/VP or Supervisor’s Signature: _____________________________________ Date: _______________________________ Worker’s Signature: _________________________________________ Date: _________________________________ Copies to: Associate Superintendent (via e-mail) P/VP or Supervisor (redacted version to be shared with JOHS Committee) HR () District Behavioral Consultant () Worker Redacted) File this completed form, in a binder, in a secure location in the administrator’s office
Form 1 Worker’s Statement of Incident *This form is N/A for worker to worker incidents School Site: Specific Location: Date & Time of Incident: Date & Time Worker Reported Incident: Name of Worker Involved in Incident: Work Phone Number: Position: Name of P/VP or Supervisor Work Phone Number: Name of Witnesses: 1. 2. 3. In your best professional judgment, this incident involving violence can be best categorized as: Verbal abuse Verbal Threat Written Threat Threatening Gestures Physical Assault Weapon Involved: If yes, specify: Aggressor’s Name (if known): Parent Other Student DOB: Grade: Nature of Injury: (include body area/part affected: left, psychological etc. Did you seek Aid? Did you see a physician? If yes, complete form 6A If yes, when? Provide dates: Were you absent from work? If yes, complete form 6A If yes, when? Provide dates: Description of Violent Incident: (Attach supporting documents as required. Inc. sequence of events, sketch, equipment, etc). Next Steps/Action Taken: Completed Form 2 No Further Action Required P/VP or Supervisor’s Signature: _____________________________________ Date: _______________________________ Worker’s Signature: _________________________________________ Date: _________________________________ Copies to: Associate Superintendent (via e-mail) P/VP or Supervisor (redacted version to be shared with JOHS Committee) HR () District Behavioral Consultant () Worker Redacted) File this completed form, in a binder, in a secure location in the administrator’s office