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This material is for training purposes only to inform the reader of occupational safety and health best practices and general compliance requirements and is not a substitute for provisions of the OSH Act of 1970 or any governmental regulatory agency.

Sample Threat and Assault Log

This type of log can help summarize and characterize reports of threats and assaults in your company over the course of a year. This information may prove helpful to your workplace violence prevention group (or administrator) when considering the need for additional hazard assessment, prevention measures or training.

Threat and Assault Log Year____________

Threat & Assault Information

January - June

July - December

Total
Number of Threats & Assaults      
Type of Threat or Assault # Threats # Assaults # Threats # Assaults # Threats # Assaults
Type 1 / Threat or assault by stranger            
Type 2 / Threat or assault by customers/clients            
Type 3 / Threat or assault by co-workers            
Type 4 / Threat or assault by personal relations            
Gender of Victims and Perpetrators # Threats # Assaults # Threats # Assaults # Threats # Assaults
Number of female victims            
Number of male victims            
Number of female perpetrators            
Number of male perpetrators            
Time of Threats & Assaults # Threats # Assaults # Threats # Assaults # Threats # Assaults
Day shift            
Evening shift            
Night shift            
On weekend            
Location of Threats & Assaults # Threats # Assaults # Threats # Assaults # Threats # Assaults
On work premises            
Parking lot            
Other duty station            
Other Considerations # Threats # Assaults # Threats # Assaults # Threats # Assaults
Threats and assaults involving firearms            
Threats and assaults involving other weapons (not firearms)            
Number of cases where the victim was working in isolation            
Result of Threats & Assaults
Death      
Physical injury      
Stress/psychological impairment      
No injury      

Adapted from: Workplace Violence: Awareness and Prevention for Employers and Employees, Washington State Department of Labor and Industries

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