This log must be used for every workplace violence incident that occurs in our workplace.  At a minimum, it will include the information required by LC section 6401.9(d).

The information that is recorded will be based on:

• Information provided by the employees who experienced the incident of violence.
• Witness statements.
• All other investigation findings.

All information that personally identifies the individual(s) involve will be omitted from this log, such as:

• Names
• Addresses – physical and electronic
• Telephone numbers
• Social security number

Enter the date the incident occurred (Day, Month, Year)

Workplace Violence Type

• Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting.
• Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object.
• Threat of physical force or threat of the use of a weapon or other object.
• Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.
• Animal attack.
• Other.

Explain

Provide a detailed description of the incident and any additional information on the violence incident type and what it included.

Workplace violence committed by:

For confidentiality, only include the classification of who committed the violence, including whether the perpetrator was a client or customer, family or friend of a client or customer, stranger with criminal intent, coworker, supervisor or manager, partner or spouse, parent or relative, or other perpetrator.

Circumstances at the time of the incident:

Type what was happening at the time of the incident, including, but not limited to, whether the employee was completing usual job duties, working in poorly lit areas, rushed, working during a low staffing level, isolated or alone, unable to get help or assistance, working in a community setting, or working in an unfamiliar or new location.

Where the incident occurred:

Such as in the workplace, parking lot or other area outside the workplace, or other area.

Consequences of the incident, including, but not limited to:

• Whether law enforcement was contacted and their response.
• Actions taken to protect employees from a continuing threat or from any other hazards identified as a result of the incident.
• Other (list below)

Explain consequences of the incident:

Were there any injuries? Yes or No. Explain:

Were emergency medical responders other than law enforcement contacted, such as a Fire Department, Paramedics, On-site First-aid certified personnel? Yes or No. If yes, explain:

Did the severity of the injuries require reporting to Cal/OSHA?

If yes, document the date and time this was done, along with the name of the Cal/OSHA representative contacted.

A copy of this violent incident log needs to be provided to the employer. Indicate when it was provided and to whom.

Submitting this form electronically will send it to the UUCD Admin. Please check that it was received by emailing office@uudavis.org. Thank you.

This violent incident log was completed by:

Name (will be considered your signature), Job Title, Date

Submit

Submitting this form electronically will send it to the UUCD Admin.

Please check that it was received by emailing office@uudavis.org.

Thank you.