Violent Incident Report - Online IDENTIFYING INFORMATION Name: * First and Last Name Worksite: * Non-Board Email Address: * Assailant * Parent Student Visitor/Member of the Public Other (Specify): Grade Level of Assailant * Specify: INCIDENT AND INJURY INFORMATION Date Of Incident: * mm/dd/yyyy Time 12:00 AM12:10 AM12:20 AM12:30 AM12:40 AM12:50 AM1:00 AM1:10 AM1:20 AM1:30 AM1:40 AM1:50 AM2:00 AM2:10 AM2:20 AM2:30 AM2:40 AM2:50 AM3:00 AM3:10 AM3:20 AM3:30 AM3:40 AM3:50 AM4:00 AM4:10 AM4:20 AM4:30 AM4:40 AM4:50 AM5:00 AM5:10 AM5:20 AM5:30 AM5:40 AM5:50 AM6:00 AM6:10 AM6:20 AM6:30 AM6:40 AM6:50 AM7:00 AM7:10 AM7:20 AM7:30 AM7:40 AM7:50 AM8:00 AM8:10 AM8:20 AM8:30 AM8:40 AM8:50 AM9:00 AM9:10 AM9:20 AM9:30 AM9:40 AM9:50 AM10:00 AM10:10 AM10:20 AM10:30 AM10:40 AM10:50 AM11:00 AM11:10 AM11:20 AM11:30 AM11:40 AM11:50 AM12:00 PM12:10 PM12:20 PM12:30 PM12:40 PM12:50 PM1:00 PM1:10 PM1:20 PM1:30 PM1:40 PM1:50 PM2:00 PM2:10 PM2:20 PM2:30 PM2:40 PM2:50 PM3:00 PM3:10 PM3:20 PM3:30 PM3:40 PM3:50 PM4:00 PM4:10 PM4:20 PM4:30 PM4:40 PM4:50 PM5:00 PM5:10 PM5:20 PM5:30 PM5:40 PM5:50 PM6:00 PM6:10 PM6:20 PM6:30 PM6:40 PM6:50 PM7:00 PM7:10 PM7:20 PM7:30 PM7:40 PM7:50 PM8:00 PM8:10 PM8:20 PM8:30 PM8:40 PM8:50 PM9:00 PM9:10 PM9:20 PM9:30 PM9:40 PM9:50 PM10:00 PM10:10 PM10:20 PM10:30 PM10:40 PM10:50 PM11:00 PM11:10 PM11:20 PM11:30 PM TYPE OF VIOLENCE The Occupational Health and Safety Act defines workplace violence as: ♦ The exercise of physical force by a person against a worker, in a workplace, that causes or could cause physical injury to the worker; ♦ An attempt to exercise physical force against a worker, in a workplace, that could cause physical injury to the worker; ♦ A statement or behaviour that it is reasonable for a worker to interpret as a threat to exercise physical force against the worker, in a workplace, that could cause physical injury to the worker Type of Violence: * Pinching Hair Pulling Verbal Spitting Scratching Biting Threatening Pushing Kicking Striking Sexual Near Miss Other (Specify) Specify type of Violence: Location: * An Employee Accident/Violent Incident Form must also be completed. Please check here to indicate that this form was completed using HPEDSB’s Online Accident/Incident Reporting Tool. * Yes Date the Board’s Online Accident/Incident Reporting Tool was completed: * mm/dd/yyyy Time 678910111212345 : 0030 AMPM Please contact the Health and Safety Chair at healthandsafety.etfohp@gmail.com once you have received follow-up information from your Administrator. Was First Aid obtained? * Yes No Were the police called? * Yes No Was medical attention received? * Yes No OTHER INFORMATION Has the assailant been involved in any previous violent incidents with staff? * Yes No Don't Know Are there any measures in place to prevent a similar incident? * Yes, for example a Safety Plan No Don't Know If the child is on a Safety Plan, has a debriefing with all individuals involved in the incident occurred or is one scheduled to occur as per procedure 379 * Yes No Child does not have a Safety Plan Procedure 379 (excerpt from page 5) Part 3: Principal Responsibilities Principals are ultimately responsible for the safety of students and employees at the school. The principal is required to conduct an investigation into all potential and reported incidents of unsafe conditions and establish a plan to alleviate the safety concern. In addition, the principal is responsible for establishing and communicating clear processes for the development, review and communication of Safety Plans. c) Investigation of incidents iv) Debriefing all individuals impacted by the incident following the incident (e.g. how are you feeling, how can I support, what happened, what might be considered next time, TCI Life Space Interview, etc.) v) Following any serious incident, working with the established in-school team and others as appropriate to review the Safety Plan and making necessary revisions and communicating the revised Safety Plan to employees working regularly and directly with the student. If the child is on a Safety Plan, is a review of the Safety Plan (to make necessary revisions) by the in-school team scheduled to occur? (as per Procedure 379) * Yes No Child does not have a Safety Plan Please provide any other information you think is relevant (Please do not use the name(s) of student(s) or other colleagues): * Did you also complete the Safe Schools Incident Reporting Form using the HPEDSB Online EMPLOYEE INCIDENT/ACCIDENT FORMS AND SAFE SCHOOLS STUDENT INCIDENT REPORTING Tool * Yes No Δ Return to Accident/Violent Incident Reporting