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Hawking STEAM Charter School
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WVPP Incident Report (For Administrators)
WVPP Incident Report (For Administrators)
Nature of incident (Check all that apply)
Answer required for "Nature of incident (Check all that apply)"
Threat
Verbal
Written
Physical with injury
Physical without injury
Harassment
Information Only
Electronic
Behavioral Observation
Other:
Date of incident?
*
Answer required for "Date of incident?"
Approximate Time:
*
Answer required for "Approximate Time:"
Incident Directed at: (Person(s))
*
Answer required for "Incident Directed at: (Person(s))"
Worksite:
*
Answer required for "Worksite:"
Hawking 1
Hawking 2
Other:
Location (where on site?)
*
Answer required for "Location (where on site?)"
Incident initiated by: (Person(s))
*
Answer required for "Incident initiated by: (Person(s))"
Gender
*
Answer required for "Gender"
Male
Female
Other:
Classification/role:
*
Answer required for "Classification/role:"
Worksite:
*
Answer required for "Worksite:"
Hawking 1
Hawking 2
Other:
Type of contact:
*
Answer required for "Type of contact:"
In person
Telephone
Mail
Observation
Recording
Electronic Mail
Other:
Was the employee alone?
*
Answer required for "Was the employee alone?"
Yes
No
Location of incident:
*
Answer required for "Location of incident:"
Workplace
Employee residence
Other:
What address did the incident occur at? (street, city, zip code)
*
Answer required for "What address did the incident occur at? (street, city, zip code)"
What type of incident was it?
*
Answer required for "What type of incident was it?"
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 students or visitors.
TYPE 3: Workplace violence against an employee by a present or former employee 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.
Were any threats made before the incident occurred?
*
Answer required for "Were any threats made before the incident occurred?"
Yes
No
If yes, describe threat(s):
*
Answer required for "If yes, describe threat(s):"
Did the employee(s) ever report to the department that he/she was threatened, harassed, or suspicious that the attacker may become violent?
*
Answer required for "Did the employee(s) ever report to the department that he/she was threatened, harassed, or suspicious that the attacker may become violent?"
Yes
No
Was the perpetrator a stranger, co-worker, or otherwise familiar person?
*
Answer required for "Was the perpetrator a stranger, co-worker, or otherwise familiar person?"
Was a weapon used?
*
Answer required for "Was a weapon used?"
Yes
No
If yes, what type of weapon?
*
Answer required for "If yes, what type of weapon?"
Was there any injuries?
*
Answer required for "Was there any injuries?"
Yes
No
If yes, complete the work injury report (Located at front desk).
*
Answer required for "If yes, complete the work injury report (Located at front desk)."
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