TWC Risk and Security Management Form RSM-3120

Oct 2017

Incident Report
Section I — General Information
Board Area / Office / Region: / Contractor (If applicable):
Incident Type: Click here to selectAnimal Bite/ThreatBomb ThreatBreaking and EnteringCivil DisturbanceDomestic ViolenceFireHarassmentIllegal Drug IncidentOther (explain)Physical BatterySecurity BreachStolen VehicleTheftWorkplace ViolenceVandalism/Intentional DamageVerbal/Physical ThreatGeneral Health Issue / Incident Date / Incident Time / Report Date
Explain Other:
Location of Incident (Address, Bldg., Room, etc.)
Program: Click here to selectBlind ServicesUIVoc RehabOtherWIOAChoicesSNAP E&T
Section II — Description of Incident
  1. Was there an injury? Click to selectYesNo. If yes, please describe the injury.
  1. Briefly summarize the incident, please include who, what, where, when, how, why.

Section III — Report to Other Agencies
  1. Has the incident been reported to other agencies or responsible officials?Click to selectYesNo
If yes, name of agency(ies) or officials: ; Report number:
  1. Is a copy of the outside report attached? Click to selectYesNo
  1. Has there been Media Coverage? Click to selectYesNo
If yes, please describe coverage. Attach copies of any relevant materials, such as newspaper clippings, recordings or Internet links.
Section IV — Subject Information
First Subject: Employee Person Involved WitnessWorkforce Board StaffOther
Name / If State of Texas employee, specify agency/department.
Address
Home Telephone No. / Work Telephone No. / ID (type, number)
Second Subject: Employee Person InvolvedWitnessWorkforce Board StaffOther
Name / If State of Texas employee, specify agency/department.
Address
Home Telephone No. / Work Telephone No. / ID (type, number)
Section V — Property Involved (description, tag/serial numbers, value, damage, etc.)
  1. Was there property damage? Click to selectYesNo. If yes explain the damage. Include estimated value of property.

Section VI — Emergency Services
Was call made for emergency responders/law enforcement? Click to selectYesNo
(Attach copy of police report, if available.)
First Notification/Respondent: Click to selectAmbulance/EMTFire DepartmentPolice/SheriffSecurity ServicesOther
Time Called / Arrival Time / Departure Time / Name Officer in Charge / Badge/Vehicle No.
Second Notification/Respondent: Click to selectAmbulance/EMTFire DepartmentPolice/SheriffSecurity ServicesOther
Time Called / Arrival Time / Departure Time / Name Officer in Charge / Badge No.
Additional Notification/Respondent:Click to selectAmbulance/EMTFire DepartmentPolice/SheriffSecurity ServicesOther
Time Called / Arrival Time / Departure Time / Name Officer inCharge / Badge No.
Section VII – Security Measures(what security measures have been taken such as increased security, added controlled access, posted picture of subject, etc.)
Section VIII – Other Information
  1. Are there any relevant documents/records available? Click to selectYesNo If yes, please describe.
  2. Are copies of the relevant documents attached? Click to selectYesNo If no, where are the records/documents located?

Section IX – Submitting the Form
Form completed by: / Position Title: / Work Phone:
All Officessubmit form to WorkforceBoard Staff at .
Additional Routing (For use by Workforce Board staff only)
Local Workforce Solutions Officesalso submit form to their appropriate RPSMClick here for
Please call for regional questions or assistance –Click here for phone numberBrewton, Chuck 210-805-2206, cell 210-413-8920Brown, Du 806-783-2983, cell 806-252-4777Duran, David 817-436-4141 X2441, cell 817-233-2182Gerhardt, Bob 512-407-1350, cell 512-565-4049Lopez, Diana 713-267-8518, cell 713-449-7622Niemann, Tangela 512-377-0505Ruiz, Albert 512-424-4074, cell 512-705-1537.

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