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Hawking STEAM Charter School
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Staff Incident Report
Staff Incident Report
Please complete the form below. Required fields marked with an asterisk *
Name
*
Answer Required
Location
*
Answer Required
Phone
*
Answer Required
Email
*
Answer Required
Job Title
*
Answer Required
Incident Time
*
Answer Required
Incident Date
*
Answer Required
Incident Location
*
Answer Required
Classroom
Hallway
Reception Area
Bathroom
Staff Lounge
Cafeteria
Parking Lot
Other Shared Area
Personal Residence
Other:
Incident Description: use the Incident Description sheet for long entries
*
Answer Required
Classification of Person Who Committed the Act
*
Answer Required
Co-worker
Supervisor/manager
Vendor/Supplier
Student
Parent
Visitor
Stranger
Other:
Violence Type - Classification (mark one)
*
Answer Required
Please Select
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 customers, clients, patients, students, inmates, or visitors.
Type 3 - workplace violence against an employee by a present or former employee, supervisor, 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.
Violence Type - Detail (Mark as needed)
*
Answer Required
Physical Attack-Biting
Physical Attack-Choking
Physical Attack-Grabbing
Physical Attack-Hair Pulling
Physical Attack-Kicking
Physical Attack-Punching
Physical Attack-Slapping
Physical Attack-Pushing
Physical Attack-Pulling
Physical Attack-Scratching
Physical Attack-Spitting
Physical Attack-Other
Weapon or Object-Firearm
Weapon or Object-Knife
Weapon or Object-Other
Threat of physical force
Threat of use of a weapon
Threat of use of other object
Threat of Sexual Assault
Sexual Assault-Rape
Sexual Assault-Attempted Rape
Physical Display of Sexual Parts
Sexual Comments
Other Physical Sexual Conduct
Other:
Medical Assistance Provided
*
Answer Required
Please Select
Yes
No
Agencies Contacted
*
Answer Required
Law enforcement
Other:
Confirmation Email
Confirmation Email
Email Required
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