Short answer: it is a factual, de-identified record of the event—not a witness statement and not the full investigation file. Include the date, time, location, violence type, circumstances, perpetrator classification, what happened, consequences, response, and corrective actions. Do not include names or other personal identifying information.
This sample is intentionally specific about the event and intentionally nonspecific about the people.
| Date, time, location | July 10, 2026, approximately 4:20 p.m.; checkout area near the east entrance. |
|---|---|
| Violence type | Type 2 — customer or client violence. |
| Perpetrator classification | Customer; no known employment relationship. |
| Circumstances | Employee was completing a return. Customer became verbally aggressive after being told the item did not meet the posted return policy. Staffing was two employees in the front area; no security staff were present. |
| What happened | Customer pushed a display toward the employee and struck the employee's forearm while reaching across the counter. A second employee called 911. Customer left through the east entrance before police arrived. |
| Consequences and response | Employee received on-site first aid and declined additional care at that time. Police report taken. Camera footage preserved. Two witnesses identified for the separate investigation file. |
| Actions taken | Return procedure reviewed; manager coverage added for disputed returns; display moved to keep the counter path clear; affected staff retrained on summoning help and disengagement. |
| Completed by | Workplace safety coordinator, July 11, 2026. |
Why there are no names: the law bars personal identifying information in the violent incident log. Keep names, contact details, medical information, detailed witness statements, and evidence in the appropriate separate files with controlled access.
Use the best known time and a useful work-area description.
Classify the event as Type 1, 2, 3, or 4 and describe the person's relationship to the workplace without identifying them.
State what occurred before, during, and immediately after the event in neutral language.
Include relevant staffing, activity, isolation, lighting, access, or other conditions.
Record security or law-enforcement contact, medical response in non-identifying terms, and operational impact.
List investigation, hazard correction, plan review, and training actions, with enough detail to show follow-through.
Use a job title or other non-identifying method if putting a name in the log would create identifying information.
Confirms employers may create their own log if it contains the required information.
The required log fields, personal-information restriction, access rules, and retention period.