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Workplace Violence Reporting Form

A reportable violent incident is any threatening remark or overt act of physical violence against a person(s) or property. Do not include a patient’s name or any health information that may compromise a patient's right to privacy.

Provide a detailed description of the incident and any additional information on the violence incident type and what it included.

Note: It’s important to understand that “Workplace Violence Type” and “Type of Incident” have separate requirements. For this part of the log, “Type of Incident” specifically refers to the nature or characteristics of the incident being logged.

  • Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting.
  • Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object.
  • Threat of physical force or threat of the use of a weapon or other object.
  • Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.
  • Animal attack.
  • Other.

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(661) 322-2206

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Main Number

(661) 322-2206

Patient Navigation

(661) 865-2573



UCLA Jonsson Comprehensive Cancer Center TRIO-US Site

© 2022 Comprehensive Blood & Cancer Center. All Rights Reserved.
Privacy Policy | Sitemap | Home