Safety and Incident Reports

Kodiak Workplace Violence Hazard or Incident Reporting Form

Complete this form to report a workplace violence incident to help the company investigate and respond appropriately to the event in a timely manner. This report will be forwarded to personnel on the Kodiak Team Member Relations TMR and Kodiak Safety Teams who have been designated to receive this information under the Kodiak Workplace Violence Prevention Plan. Please describe the hazard or incident in detail so that the company can gain an accurate understanding of the hazard or incident as this will aid the company in its investigation and mitigation efforts.

Section 1: Information About the Person Completing This Report

Name

(Leave Blank If Reporting Anonymously)

Job Title(Required)

Date Submitted(Required)

Section 2: Hazard or Incident Information

Date of Hazard/Incident(Required)

Time of Hazard/Incident(Required)

Location of Hazard/Incident(Required)

Include job name number if applicable

Describe Specific Area of Location(Required)

Be Specific e.g. NW corner of Fabrication Area, East Parking Lot, Building C Roof etc.

Describe the Type of Hazard or Person Who Committed the Violence Incident(Required)

e.g. Access Door Left Open, Unidentified Person(s) Wondering Around Office, Coworker, Spouse of Coworker, Stranger, etc.

List Witnesses(Required)

Describe the Violence Hazard or Incident in Detail(Required)

. If possible, recall and describe circumstances surrounding the hazard or incident including but not limited to, poor lighting, open access door, employee who experienced the violence was working at usual assigned work duties, working without proper staffing levels, was working alone, working in a new/unfamiliar location, etc.

This field is for validation purposes and should be left unchanged.