Secure workplace violence report

Report On-Duty Violence, Threats, or Aggression

This intake is designed for fast, structured reporting when details may still be fresh and stress is high. Complete the required sections first, then add optional pattern details if they will help your agency or researchers understand what happened.

Most reporters finish the required fields in about five minutes on a phone.

Only the fields marked with * are required to submit.

Leave out names, dates of birth, exact addresses, MRNs, and other PHI.

Report progress

Required items first. The optional section can be skipped if you need to move quickly.

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This form does not autosave. If you leave before submitting, your draft will be lost.

Review snapshot

Key details are summarized here so you can review them before submitting.

Nothing entered yet

Start with incident basics. As you move through the form, your key details will appear here for a quick final review.

Privacy reminders

Do not include patient names, DOBs, addresses, record numbers, or other identifiers.

Short, factual answers are enough. You can skip the optional pattern section.

This submission supports reporting and pattern tracking, but not emergency dispatch.

Report progress0% complete

Step 1

Only the required items need to be completed to submit the report.

County, agency, and unit number are optional and can be left blank if unknown.

State*

Required. Choose the state or territory where the event happened.

County / parish / borough

Optional. Uses the official county-equivalent list for the selected state or territory.

Agency

10 agencies available. Start typing to filter, or enter your own if needed.

Truck apparatus or unit number

Optional. Include the responding or transport unit if it helps your internal review.

Service area*

Required. Choose the environment that best matches the event.

Service type involved*

Required. Select every service type that applies.

Air MedicalGround AmbulanceCommunity Paramedic VisitOther

When did it happen?*

Required. Use the best known date and time.

When during the call or transport?*

Required. Choose the stage that best describes the event.

Start with the essential incident details. County, agency, and unit number are optional.

Involvement not entered • Role not entered • Employment type not entered

Harm level not entered • Destination not entered • Distance not entered

Skip this section if you only need to complete the required report.

Narrative not entered • PHI confirmation pending • Reporting notice pending

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