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Violence in the Workplace Incident Report Village of Gowanda Date of Incident: Time of Incident: Employee(s) Name: Title: Workplace Location: What was employee.doing just prior to incident: Incident Description (including names of involved employees, types of injuries, verbal/physical, names of witnesses): List preventive actions that the employer has taken of is considering as a result of this incident to prevent against future occurrences: Employer is responsible for maintaining any and all copies of any and all reports. Employee Signature: Authorized Employee Representative Signature: Date: