General Information

Name of Person Committing the Act of Violence

Classify Subject

Gender of Assailant

Was the Assailant Armed With a Weapon?

Violence Directed Towards:

Predisposing Factors of Assail


Description of Incident
Date and Time of Incident

Location of Incident

Physical abuse?


Extent of injuries:

Verbal abuse?

Describe if other type of abuse:

Detailed description of incident

Did anyone leave the area due to the incident?


Was Security requested?

Did Security respond in a timely fashion?

Did the Police Dept respond to assist?

Termination of Incident

Incident diffused?

Police notified?

Assailant arrested?

Disposition of Assailant

Restraints used?

Was Risk notified?

Person completing report signature

Type name and title of person completing report

Select date
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.