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

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 ATTACHMENT 3

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.

VIOLENCE INCIDENT STATEMENT

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.

Report Completed By:	Date: