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FORM H- San Joaquin Violence in the Workplace Incident Report <br /> Print Form <br /> 2689.17 Workplace Violence Incident Report Form <br /> San Joaquin County requires the supervisor of the alleged victim complete this form when a <br /> violent act or threat of violence occurs in the workplace as outlined in the Workplace Violence <br /> Prevention Policy. <br /> Send completed form to Human Resources, Risk Management Office, 44 N. San Joaquin <br /> Street, Suite 330, or fax: 953-7330, (Form must be received within 24 hours via fax or <br /> email.) SJCRISKMGMTPsigov.org <br /> Date of Incident: Time: <br /> Date reported: <br /> Location of Incident: <br /> Description of Incident or Threat (use additional paper if necessary): <br /> Name of Perpetrator if known): <br /> Perpetrator's Relationship to County if known): <br /> Weapons Involved:Yes F No F If yes, specify: <br /> Name of Victim: <br /> Department: Phone: <br /> In'uries:Yes r No I_._ If Yes specify: <br /> Witness(es) Include witness written Department: <br /> statement: <br /> Phone: <br /> Law Enforcement Notified:Yes I— No F_ <br /> If Yes Name of Agency and Report Number: <br /> Property Damage:Yes 1F".v No f If Yes specify: <br /> Corrective Action(s) Taken: (Use additional paper if necessary) <br /> Recommended Corrective Action(s) (use additional paper if necessary): <br /> Provided Employee Assistance Program Information: Yes 7 No f <br /> Department Representative who Phone: <br /> completed this form: <br /> Rev 2-07 <br /> Updated Address Revision M9 <br /> Corrected Typos 5-13 San Joaquin County Administrative Manua! <br /> San Joaquin County <br /> Department of Public Works <br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 33 <br />