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Hawking STEAM Charter School
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WVPP Incident Report (For Administrators)
WVPP Incident Report (For Administrators)
Nature of incident (Check all that apply)
Answer Required
Threat
Verbal
Written
Physical with injury
Physical without injury
Harassment
Information Only
Electronic
Behavioral Observation
Other:
Date of incident?
*
Answer Required
Approximate Time:
*
Answer Required
Incident Directed at: (Person(s))
*
Answer Required
Worksite:
*
Answer Required
Hawking 1
Hawking 2
Other:
Location (where on site?)
*
Answer Required
Incident initiated by: (Person(s))
*
Answer Required
Gender
*
Answer Required
Male
Female
Other:
Classification/role:
*
Answer Required
Worksite:
*
Answer Required
Hawking 1
Hawking 2
Other:
Type of contact:
*
Answer Required
In person
Telephone
Mail
Observation
Recording
Electronic Mail
Other:
Was the employee alone?
*
Answer Required
Yes
No
Location of incident:
*
Answer Required
Workplace
Employee residence
Other:
What address did the incident occur at? (street, city, zip code)
*
Answer Required
What type of incident was it?
*
Answer Required
TYPE 1: Workplace violence committed by a person who has no legitimate business at the worksite, and includes violent acts by anyone who enters the workplace or approaches workers with the intent to commit a crime.
TYPE 2: Workplace violence directed at employees by students or visitors.
TYPE 3: Workplace violence against an employee by a present or former employee or manager.
TYPE 4: Workplace violence committed in the workplace by a person who does not work there, but has or is known to have had a personal relationship with an employee.
Were any threats made before the incident occurred?
*
Answer Required
Yes
No
If yes, describe threat(s):
*
Answer Required
Did the employee(s) ever report to the department that he/she was threatened, harassed, or suspicious that the attacker may become violent?
*
Answer Required
Yes
No
Was the perpetrator a stranger, co-worker, or otherwise familiar person?
*
Answer Required
Was a weapon used?
*
Answer Required
Yes
No
If yes, what type of weapon?
*
Answer Required
Was there any injuries?
*
Answer Required
Yes
No
If yes, complete the work injury report (Located at front desk).
*
Answer Required
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