KNOWSLEY METROPOLITAN BOROUGH COUNCIL
VIOLENT INCIDENT REPORT
THIS REPORT SUPPLEMENTS ACCIDENT FORM ARF1 or ARF2
AND SHOULD BE USED SPECIFICALLY FOR VIOLENT INCIDENTS
1. DETAILS OF THE VIOLENT PERSON [if more than 1 person, use additional form]
Surname: / Forename / D.o.B if knownHome Address:
Other known alias or address:
2. STATUS OF THE VIOLENT PERSONS
Customer / Client Other please state who - e.g. spouse or partner of customer, member of same household etc ……………………………...
3. TYPE OF INCIDENT
Physical assault, grievous bodily harm which entailed being detained in hospital for 24 hrs ………
Physical assault, actual bodily harm causing injury …………………………………………………
Physical assault with no injury common assault………………………………………………………
Threat with a weapon ………..………………………………………………………………………
Threat of violence in person ………………………………………………………………
Threat of violence over the telephone or in correspondence …………………………………
Harassment incl. threatening, abusive, insulting language or behaviour; stalking.…………………
4. INFORMATION SUPPLEMENTARY TO THE DETAILS ON ARF1 or ARF2:
Confirm - Date of Incident / Time / LocationInclude any events leading upto the incident.
Do You think this may have been motivated due to: Drugs or Alcohol Racial or Sexual
5. ACTION FOLLOWING THE INCIDENT – this must be discussed and agreed with your Manager
No further actionKMBC Banning Order / impose restrictions
Warning letterEmployee Support/Counselling required
Discuss/Review procedures
There are valid concerns regarding formal notification that the VP will be entered on the register
Police to prosecute assailant [a formal report of the incident must be made to the police]
Employee is proposing to take out a civil claim against the PVP
Other please specify. …………………………………………………………………………………………………
6. The above information must be discussed personally with the employees Supervisor [or if a non-employee the Building Manager], who must undertake an investigation and outline the proposed action on form ARF1 or ARF2.
Signature of injured person: …………………………………………Date ……………………
Signature of Supervisor/Bld Manager : ………………………………Date ……………………
This form MUST beattached to the ARF1 or ARF2 and sent toCorporate Health and Safety within 3 days of being reported and if for an Employee an entry must also be made in the accident book.
IMPORTANT - There are certain types of accidents/occurrences that require IMMEDIATE notification by telephone to Corporate Health and Safety; these are the more serious type of accidents involving fractures, being detained in hospital for 24 hrs, acts of violence ... etc. or dangerous occurrences, if unsure contact your Corporate Health and Safety.