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DEPARTMENT OF PUBLIC SAFETY WORKPLACE VIOLENCE VICTIM/WITNESS ACCOUNT FORM To be completed by victims of witness to alleged workplace violence. Reproduce as needed. Date of Incident
Name Victim
Witness
Address of witness/victim
Date of Report
Phone Number
Describe Incident in detail. Include what happened, where, who was involved, what you heard, saw, etc.
List of Names of Other Witnesses
Signature
Person Receiving Witness Statement
Form HR 549a Workplace Violence Victim/Witness Account Form Form last revised March 2014 NC Department of Public Safety
Date
Date
Page 1 of 1
DEPARTMENT OF PUBLIC SAFETY WORKPLACE VIOLENCE VICTIM/WITNESS ACCOUNT FORM To be completed by victims of witness to alleged workplace violence. Reproduce as needed. Date of Incident
Name Victim
Witness
Address of witness/victim
Date of Report
Phone Number
Describe Incident in detail. Include what happened, where, who was involved, what you heard, saw, etc.
List of Names of Other Witnesses
Signature
Person Receiving Witness Statement
Form HR 549a Workplace Violence Victim/Witness Account Form Form last revised March 2014 NC Department of Public Safety
Date
Date
Page 1 of 1
