Employee Abuse Report Form
This document is to be filled out by an employee reporting abuse at the workplace. The contents will remain confidential and the issues shall be addressed. You can customize this template with your company name and logo and any additional information you’d like to collect. It is for example purposes only and neither YWCA Hamilton, nor WPH will be liable to you for any damages, direct or indirect arising from the use of this template.

Your Name:

	Your position:	
Date:

	Project/Location:	
Name(s) of Supervisor(s):

	Date and Time of Incident:	
Respondent’s Name (The person who the incident was reported to):

	Location of Incident:	

1. Which type of abuse are you reporting? Circle the options that apply:
Physical 		Verbal 			Emotional 		Other:

2. Have you reported the incident (s) verbally to a supervisor? Circle one:
Yes 			No

3. What was the relationship of the abuser to you? Circle the options that apply:
Co-Worker		Client/Customer	Member of Public	Other (please specify)

4. Where did the abuse occur? (e.g.: on construction site, in parking lot) Write your answers in the space provided below:

5. Did you miss any time from work as a result of the violence or harassment? Circle one:
Yes 			No

6. If yes, please indicate the length of absence from work. (# of days/weeks/months)

7. Do you:
a. Work alone or with a small number of co-workers?
Yes			No
b. Work late at night or early in the morning?
Yes 			No
c. Are you concerned about your safety on the job?
Yes 			No

Please provide any additional comments: