Violent Incident Report For the NBTF use only. CONFIDENTIAL. Date of Incident* Date Format: MM slash DD slash YYYY Time of Incident : HH MM AM PM REPORTING EMPLOYEEName* First Last District*ASD-EASTASD-SOUTHASD-WESTASD-NORTHDSF-NORD-ESTDSF-NORD-OUESTDSF-SUDSchool / Workplace*Position / Job TitleReplacing an Education Assistant* Yes No Relationship of ALLEGED AGGRESSOR(s) to REPORTING EMPLOYEECo-WorkerStudentParentPublicGenderMaleFemaleApproximate AgeWitness? Yes No Type of Incident* Threat Weapon Threat Physical Agression Intimidation Harassment Social Media Destruction of Property Location of IncidentShort Description of IncidentUpload picture of incident, if availableReported to Principal Yes No Reported to District Yes No I don't know Did you have to take time off as a result of this incident? Yes No Results / Follow-upWould you like to be contacted by a Labour Relations Officer?* Yes No Email* Would you like the NBTF to share this information with your school district?* Yes No Uncertain (A Labour Relations Officer will contact you) Email* Hurt at work? Start the claims process. If you’ve lost time from work and/or need medical treatment beyond first aid because of a work-related injury or illness, you’ll need to complete WorkSafeNB’s Application for Workers’ Compensation Benefits within 3 days of the incident or as soon as possible.
