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It defines intended users, including impacted workers, supervisors, and the employer or designate, and specifies how Sections A, B, and C must be completed, reviewed, signed, and filed. The form guides documentation of incident type, harm level, nature and source of violence, person identification and descriptions, incident location, observed behaviours, and frequency, supporting consistent organizational reporting and follow-up.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/appendix-c-sample-workplace-violence-incident-and-injuryillness-report-form/252798/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/appendix-c-sample-workplace-violence-incident-and-injuryillness-report-form/252798.png","ImageObject",442,249,{"name":88,"@type":89},"Elsa","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-13",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should use the workplace violence incident and injury/illness report form?","Question",{"text":108,"@type":109},"Impacted workers (or those reporting on a worker’s behalf), the worker’s supervisor, and the employer or designate use the form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which sections must workers and supervisors complete?",{"text":113,"@type":109},"Workers complete and sign Sections A and B. The impacted worker’s supervisor completes and signs Sections A and B as well, ensuring completion and prompt submission as required.",{"name":115,"@type":106,"acceptedAnswer":116},"What is the process after all sections are completed and signed?",{"text":117,"@type":109},"After Sections A, B, and C are completed and signed, the report is filed in the designated department or by the designated person according to organizational policy.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},252798,1789262951,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":8,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":79},137455077381,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","APPENDIX C: SAMPLE WORKPLACE VIOLENCE INCIDENT AND INJURY/ILLNESS REPORT FORM  \nPURPOSE OF THIS TOOL  \nThe purpose of this tool is to provide a sample form to report incidents related to workplace violence.  \nWHO USES THIS TOOL  \n• Workers impacted by a workplace violence incident (or those reporting workplace violence on behalf of an injured Worker)  \n• Worker’s supervisor  \n• Employer or designate  \nHOW TO USE THIS TOOL  \nAfter a workplace violence incident occurs, the following sections of the form are completed by each of the workplace parties:  \n• The worker impacted by the incident completes and signs Section A: Workplace Violence Incident Report and Section B: Workplace Violence Injury/Illness Report  \n• The impacted worker’s supervisor completes and signs Section A: Workplace Violence Incident Report and Section B: Workplace Violence Injury/Illness Report  \n• The employer or designate completes and signs Section C: Workplace Violence Incident Notifications  \nOnce all three sections are completed and signed, the report is filed in [insert department or person where workplace violence incident reports are filed, as per organizational policy] .  \nNote: Where workplaces have one incident reporting format for all types of hazards, they should ensure that it includes space to capture workplace violence information (as listed below in the sample form – sections 4, 7, 8, and 12) .  \nWORKPLACE VIOLENCE INCIDENT AND INJURY/ILLNESS REPORT FORM  \nInstructions: Workers or those reporting workplace violence on behalf of an injured Worker must complete sections A and B of this form and submit it promptly to the Worker’s Supervisor. If additional assistance is required, complete the form with the Supervisor. The Supervisor is required to review and ensure completion and submission of the form to \u003C Name of Responsible Person > as soon as possible as per organizational policy. For potential workplace violence hazards not resulting in a workplace violence near miss or an incident, please complete a Workplace Violence Hazard Form.  \n\n| PART A: WORKPLACE VIOLENCE INCIDENT REPORT |\n| --- |\n| 1. Person Reporting |\n| Worker involved in Incident or Person Reporting Incident:\u003Cbr>First Name:   Last Name:  \u003Cbr>Employee \\#:   Department/Unit:   Job Position:   Phone Number:\u003Cbr>Date of Incident:   Time of Incident:   |\n| 2. Type of Workplace Violence Incident. Check ☒ one |\n| ☐ Near Miss (incident occurred but workplace violence did not reach the Worker – no injury/illness)\u003Cbr>☐ Not Causing Harm (incident occurred-workplace violence reached Worker – no apparent injury/illness)\u003Cbr>☐ Causing Harm (incident occurred-workplace violence reached Worker-causing injury/illness) |\n| 3. Nature of Workplace Violence Incident. Check ☒ all that apply |\n| ☐ Threat to exercise physical force that could have caused physical injury ☐ Attempt to exercise physical force that could have caused physical injury ☐ Physical force that caused or could cause physical injury |\n\n\n| 4. Source of Workplace Violence Incident. Check ☒ all that apply |\n| --- |\n| ☐ Care Recipient\u003Cbr>☐ Visitor\u003Cbr>☐ Employment Related (e. g., worker, supervisor, physician, contract worker, student etc. )☐ Person known to a Worker (e. g., spouse, partner, or relative)\u003Cbr>☐ Person unknown to Workers/Organization ☐ Uncertain |\n| 5. Person’s Identification. Check ☒ one |\n| The Person is…\u003Cbr>☐ Known to the organization (e. g., an employee)\u003Cbr>☐ Unknown to the organization (e. g., a visitor) |\n| If known, complete the following:\u003Cbr>First Name:   Last Name:   or Identifier:   How is the Person known to the organization?\u003Cbr>Address of Person, if known: |\n| If Unknown, describe the Person. E. g., gender, height, weight, features, hair/eye colour, etc. |\n\n\n| 6. Location of Incident |\n| --- |\n| Did the Incident occur on workplace premises?☐ Yes\u003Cbr>☐ No |\n| Describe the specific location, e.g., building, room, area in room, address if location outside workplace premises, public place:\u003Cbr>________________________","cbCaimxspqvGwQdW","https://ap.wps.com/l/cbCaimxspqvGwQdW","pdf",497211,"English","# Purpose of this tool\n# Who uses this tool\n# How to use this tool\n# Workplace violence incident and injury/illness report form\n## Part A: Workplace violence incident report\n## Part B: Workplace violence injury/illness report\n## Part C: Workplace violence incident notifications","[{\"question\":\"Who should use the workplace violence incident and injury/illness report form?\",\"answer\":\"Impacted workers (or those reporting on a worker’s behalf), the worker’s supervisor, and the employer or designate use the form.\"},{\"question\":\"Which sections must workers and supervisors complete?\",\"answer\":\"Workers complete and sign Sections A and B. The impacted worker’s supervisor completes and signs Sections A and B as well, ensuring completion and prompt submission as required.\"},{\"question\":\"What is the process after all sections are completed and signed?\",\"answer\":\"After Sections A, B, and C are completed and signed, the report is filed in the designated department or by the designated person according to organizational policy.\"}]","APPENDIX C - SAMPLE WORKPLACE VIOLENCE INCIDENT AND INJURY/ILLNESS REPORT FORM | PDF"]