Workplace Violence Reporting Form
This form requires Javascript to be enabled for submission and authorization.
*
Required
Half Hollow Hills Central School District
Violence/Threat Reporting Form
Name
*
required
First Name
Last Name
Phone Number (Optional)
Email Address (Optional)
Date of Incident
*
required
Must contain a date in MM/DD/YYYY format
Employee's Building
*
required
Candlewood
High School East
High School West
Otsego
Paumanok
Signal Hill
Sunquam
Vanderbilt
West Hollow
Central Office
Transportation
Hills Academy
Employee's Position
*
required
Location where incident occurred (building, online, etc):
*
required
Time of incident:
Names of anyone involved:
Detailed description of the incident, including events leading up to the incident and how the incident ended:
*
required
Names of witnesses (include statements, if applicable):
Did this incident result in injury? (If "Yes", complete the Workers' Compensation Incident/Accident Report Form within 5 days)
YES
NO
Has an employee Incident/Accident Report Form been submitted in relation to this incident (if applicable)?
YES
NO
Attach/upload any relevant documents, emails, or other incidents related to the incident
Attach up to 5 files with a maximum size of 10MB
Select File(s)
No file chosen
(Employees who are victims of workplace violence can voluntarily request that their name not be entered on the report.)
Submit