/ Workplace Violence Incident Report and Investigation
School District No. 71 (Comox Valley)

To be completed by site based staff most directly involved in the incident and by the site investigation team.

Section 115 of the Workers Compensation Act requires that employers inform their employees about all known foreseeable health and safety hazards including workplace violence. This document is required to document violent incidents to initiate a process to safeguard employees and to support student success.

4.27 Definitions – Violence in the Workplace, WorkSafeBC (WCB): Violence in the workplace means the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker, and includes any threatening statement or behaviour which gives a worker reasonable cause to believe that he or she is at risk of injury.

In the best professional judgment, this incident involving violence can be best categorized as (check all those that apply):

PART A. INCIDENT DOCUMENTATION (completed by the employee)

☐ Threat ☐ Weapon Threat ☐ Violence ☐ Intimidation ☐ Harassment

Name of affected employee: Click here to enter text. Position: Click here to enter text.

Employee’s work site: Click here to enter text. Location of incident: Click here to enter text.

Witnesses: Click here to enter text.

Date of incident: Click here to enter a date. Time: Click here to enter text. Injury to employee: ☐ Yes ☐ No

Student name (if applicable): Click here to enter text. Student no.: Click here to enter text.

Description of incident in detail: Click here to enter text.

Workplace Violence Risk Assessment

If the incident was of a violent nature, the following section must be completed. Please check the boxes that best describes the risk at work:

Intensity: How severe was the injury/trauma?

☐ Severe (injury causing hospitalization – broken bones, cuts, lacerations, concussion, fearful, unable to work)

☐ Moderate (sprain, dislocation, fracture, major bruising, upset, shaken, able to resume duties after a brief time)

☐ Low (some light bruising, scratches, swelling, soreness, upset, shaken)

☐ No injury (able to continue work)

Frequency: How often are incidents occurring? (Does documentation support previous incidents?)

☐ High (at least once per week up to one or more a day)

☐ Medium (at least once a month up to once a week)

☐ Low (at least once a year up to once a month)

PART B. PLANS/ACTIONS (completed by the school principal/supervisor and employee)

1.  Student behaviour plan is in place ☐ Yes ☐ No ☐ Not Applicable

2.  Student behaviour plan is required ☐ Yes ☐ No

3.  This person presents a risk of violence toward staff ☐ Yes ☐No

If “Yes”, District Principal, Health and Safety and Director of Instruction (Student Services) must be notified via email and Part C Incident Investigation must be completed thoroughly.

4.  Staff safety plan is in place ☐ Yes ☐ No

5.  Staff safety plan is required ☐ Yes ☐ No

6. Investigation is required ☐ Yes ☐ No

☐ I acknowledge that I represent the employer and that I have reviewed the incident and agree with the information as presented.

Administrator/Supervisor’s Signature / Date Signed

☐ I acknowledge that after review I have determined that the above described incident DOES NOT constitute a threat or risk towards me.

☐ I acknowledge that after review I have determined that the above described incident DOES constitute a threat or risk towards me and that a safety plan is required.

Employee’s Signature / Date Signed

PART C. INCIDENT INVESTIGATION (completed by site investigation team)

Investigation findings: Click here to enter text.

Conclusion/Recommendation(s) completed by investigation team: Click here to enter text.

Recommended actions (check those that apply):

Action / Action By
☐
☐
☐
☐ / Review/create student behaviour plan / Click here to enter text.
Initiate staff safety plan / Click here to enter text.
Initiate team meeting / Click here to enter text.
All of the above / Click here to enter text.

Communications: ☐ RCMP Notified ☐ Parent Notified ☐ “At Risk” Staff Notified

Click here to enter text.
Name of Site Based Committee Designate (CUPE) / Signature of Site Based Committee Designate (CUPE)
Click here to enter text.
Name of Site Based Committee Designate (CDTA) / Signature of Site Based Committee Designate (CDTA)
Click here to enter text.
Name of Site Based Committee Designate (P/VP) / Signature of Site Based Committee Designate (P/VP)

Date Form Completed: Click here to enter a date.

Once completed, please save to your computer, print, sign, scan and email to District Principal, Health and Safety.

District Principal, Health and Safety will email copies of completed form as necessary to:

·  Student Services

·  CDTA (if involving a CDTA member), copy to Director of HR

·  CUPE (if involving a CUPE member), copy to Director of HR

Reviewed by District Principal, Health and Safety / Date

(rev. Jun 6/14)

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