Supplemental Incident Report Form

SUPPLEMENTAL INCIDENT REPORT Threatening or Violent Behavior
Type of Incident:________________________________________________________________
Where did the incident occur?_______________________________________________________________
When did the incident occur? Date ______ Time________
Who was involved? 1._____________________________________________________2.________________________________________________
3._____________________________________________________4.________________________________________________
Names of Witnesses: 1._____________________________________________________2.________________________________________________
3._____________________________________________________4.________________________________________________
Names of Supervisory Staff involved: 1._____________________________________________________2.________________________________________________
Outside Agencies Contacted (Police, Human Resources, EMS, EAP, Wellness Center, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
Reports Filed: _________________________________________________________________________________________
What happened? Be specific in recording the incident (what was said, what each person did, etc.):____________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
(Use additional page(s) if necessary.)
What triggered the incident? _______________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
What ended the Incident? ___________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
What happened to the individuals (victims and offenders) immediately after the incident? _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
What action was taken? ______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
What was your role in this incident? (Witness, Supervisor, reporter, participant, etc.): _________________________________________________________________________________________________________
Was the Workplace Safety and Violence Prevention team notified? Yes / No
If "Yes," Name: ______________________________________
Date/Time Notified: _____________, ________a.m./p.m.
If "No," reason why not:______________________________________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Reporting Person:______________________________________________________________________________________ Print Sign
Supervisor:_________________________________________________________________________________ Print Sign
Distribution:	_____	Human Resources (Through your Supervisor, Assoc. Dean, Dean)
	_____	Campus Security (Through your Supervisor, Assoc. Dean, Dean)
	_____	President's Office (Through your Dean, VP, HR, & Security)
	_____	Assessment Team (Through HR & Security)
	_____	Assisting Law Enforcement Agency (Through Security)

		CNM, HR 6/06