Violent Incident Report For the NBTF use only. CONFIDENTIAL. Date of Incident* MM slash DD slash YYYY Time of Incident : AM PM AM/PM REPORTING EMPLOYEEName* First Last District*ASD-EASTASD-SOUTHASD-WESTASD-NORTHDSF-NORD-ESTDSF-NORD-OUESTDSF-SUDSchool / Workplace* Position / Job Title Replacing an Education Assistant* Yes No Relationship of ALLEGED AGGRESSOR(s) to REPORTING EMPLOYEECo-WorkerStudentParentPublicGenderMaleFemaleOther genderApproximate Age of the StudentWitness? Yes No Type of Incident* Threat Weapon Threat Physical Agression Intimidation Harassment Social Media Destruction of Property Location of Incident Short Description of IncidentUpload picture of incident, if availableMax. file size: 1 GB.Reported 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.CAPTCHA
