Violent Incident Form

Workplace Violence Reporting Form

Name (Do not enter if you want to remain anonymous)

First Last

Email(Required)

Enter Email Confirm Email

Type of Incident (Select one)(Required)

Type 1 – Violence committed by person with no connection with SJ Towing

Type 2 – Violence committed by customer or visitor

Type 3 – Violence committed by present or former employee

Type 4 – Violence committed by non-employee with relationship to an employee (ie. partner or spouse)

Unsure

Date of incident(Required)

Time of incident(Required)

As close as possible

Location of incident(Required)

Description of incident(Required)

Was law enforcement contacted?(Required)

Yes

Police Report # (if available)

This field is for validation purposes and should be left unchanged.