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Louisiana Tech University


Policies & Procedures

Policy 1430 - Attachment 3 - Violence Free Workplace Policy

Revision Date: 8/21/2002

Responsible Office: Human Resources Office

Reference: University of Louisiana System, Policy M-11, Board Rule Chapter 3, Section XIX


VIOLENCE INCIDENT STATEMENT

Note: 
The contents of this document shall be kept confidential with its contents released only to individuals with a legitimate need to know or unless it becomes public record by virtue of an appeal to a court or other adjudicative body.

Date of Incident   Place of Incident  
Time Incident Began   Time Incident Ended  
Name of Person Making Statement   Phone No.  
Title   Work Location  

Detail description of incident answer the questions WHO, WHAT, WHEN, WHERE, HOW, and WHY. (If necessary, continue on plain paper; attach sheets.) Completed statement should be forwarded to appropriate personnel.


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