HERTFORDSHIRE COUNTY COUNCIL VIOLENT INCIDENT REPORT VIR FORM

HERTFORDSHIRE COUNTY COUNCIL VIOLENT INCIDENT REPORT (VIR) FORM Appendix B DEPARTMENT__________ PERSON COMPLETING REPORT NAME & ADDRESS OF ESTABLISHMENT, OFFICE, DEPOT ETC. NAME _________________________________________________ POSITION ________________________________________ TEL NO. & EXT. _______________ DEPT LOCATION OFFICIAL USE CODE SIGNATURE. __________ CODE NATURE OF INCIDENT Verbal Written Physical DATE OFFICIAL USE (please tick as appropriate) Severe verbal abuse Harrassment Weapon PERSON IN CHARGE OF ACTIVITY AT TIME OF INCIDENT (if different from above) NAME POSITION _____________________________________ . DETAILS OF PERSON INVOLVED DETAILS OF VIOLENT PERSON (ONE PERSON PER FORM) SURNAME ____________________ OTHER NAMES _____________ ADDRESS___________________ AGE ______ OTHER RELEVANT _____________________ SEX M F INFORMATION _________________ JOB TITLE/RANK ____________ ETHNIC ORIGIN (if known) ETHNIC ORIGIN Black African Black-Carribean Black -Other Indian Pakistani Sikh Bangladeshi White Traveller Other Asian Other OFFICIAL USE DETAILS OF INCIDENT DATE EXACT LOCATION _______________ TIME ____________________ OCCURRED _____AM/PM REPORTED _____AM/PM ______________________________ FACTUAL DESCRIPTION OF EVENTS & CIRCUMSTANCES (INCLUDING HOW THE INCIDENT AROSE) (Continue on a second sheet if necessary)

DETAILS OF INJURY AND TREATMENT Was injury sustained? YES NO If YES, give details of nature, site and extent OFFICIAL USE ____________________________________________________________________ TYPE OF TREATMENT: HOSPITAL DOCTOR FIRST AID OFFICIAL USE REST NONE DETAILS OF TREATMENT _________________________ OFFICIAL USE NAME & ADDRESS OF HOSPITAL/DOCTOR (If appropriate) WITNESS/ES (continue on separate sheet if necessary) __________________________ NAME ___________________________________________ ADDRESS ________________ If an employee, has the injury resulted in absence from work? YES _____________________ (ATTACH STATEMENT) NO What time did he/she stop work? ________am/pm HSE STATUTORY REQUIREMENTS Is incident notifiable to HSE? (See Departmental Safety Arrangements) YES NO IF YES: HSE notified by phone? YES NO Anticipated duration of absence ________ days HSE form F 2508 sent? YES BY: NAME DATE If yes, did he/she do any work on the day of the incident after it happened? YES NO NO IF THIS FORM HAS NOT BEEN COMPLETED BY THE MANAGER, MANAGER MUST SIGN HERE TO INDICATE THAT THEY ARE AWARE OF ACCIDENT/INCIDENT DETAILED OVERLEAF AND ABOVE. Manager’s Name: Signature: Date: INVESTIGATION Has the incident been reported to the Police? . YES NO If YES, please give details (including when, where, officer’s names/no’s, action taken) __________________________________________ What was the likely cause of the incident and what would make it less likely to recur? __________________________________________ Give details of any discrepancies found in the information provided any action taken to investigate and prevent recurrence _____________________________________________________________________________________________ Investigating Officer: NAME POSITION NOTE: SIGNATURE TEL NO. DATE Completion of this form does not constitute a claim against the County Council. This form should be completed as soon as possible after the incident and processed in accordance with your departmental arrangements and the original sent to the CSF HEALTH AND SAFETY TEAM, ROOM 159, COUNTY HALL, HERTFORD SG 13 8 DF