SECTION 9.80 VIOLENCE-FREE WORKPLACE REPORT FORM

Last Update: 11/03

STATE OF IOWA Iowa Department of Administrative Services – Human Resources Enterprise WORKPLACE VIOLENCE REPORT
Complainant/Witness:		Telephone #:
Department/Division:		Work Location:
Person Completing Form: (Name/Title)	Date:	Telephone #:

ALLEGED OFFENDER INFORMATION (Complete the following information, if known)
Name:	Address:
Employer:	Job Title:
Relationship to Complainant/Witness: (For Example: Client, Vendor, Co-Worker, Supervisor, Spouse)

Law Enforcement Contact (If Applicable)
Date:	Agency:	Officer(s) Name:	Report Number:

INCIDENT DESCRIPTION

[Describe the alleged incident(s) in detail: who, what, when, where, why, how.]

[Attach additional pages if necessary]

FORM TO BE FILED WITH THE APPOINTING AUTHORITY AND

THE IOWA DEPARTMENT OF ADMINISTRATIVE SERVICES – HUMAN RESOURCES ENTERPRISE

WORKPLACE VIOLENCE COORDINATOR