Form
Form - Violence Incident Report
Document FSSMS-FRM-45Stage 1Revision 3Version 0.3.3
Topic pages open on your jurisdiction, and requirements tables show its line. You can change this on any page.
Complete for every incident of violence against a member: physical assault, attempted assault, threat (in person, by phone, written or online), verbal abuse that gives reasonable cause for concern, sexual harassment by a member of the public, and any flagged call where the crew staged or withdrew, whether or not contact occurred. Harassment by another member of the department is reported through the channels in Policy - Workplace Violence and Harassment clause 5.7, not on this form. The member completes Part A before the end of the shift (volunteers within 24 hours); the officer completes Part B the same day; the HSO completes Part C within two working days; the reporter receives Part D in writing within 10 working days. Some jurisdictions set reporting, investigation and reply duties for workplace violence by regulation; check that these timelines meet them (J26 Workplace Violence). Write it expecting disclosure under access-to-information law: roles, not names, for anyone other than the reporter.
| Field | Type | Required | Who completes |
|---|---|---|---|
| Part A: the incident | |||
| Report number | Auto or assigned | Yes | Records system |
| Date and time of incident | Date-time | Yes | Member |
| Incident number (CAD) | Text | Yes if a call | Member |
| Call type as dispatched | Pick list (medical; overdose; psychiatric; domestic; MVC; fire; alarm; welfare check; public assist; inspection; other) | Yes | Member |
| Location type | Pick list (private home; public place; roadway; encampment; station public area; station living area; apparatus; personal vehicle; office; online or phone; other) | Yes | Member |
| Address or location (for the caution flag) | Text | Yes | Member |
| Type of violence | Pick list, multiple (physical assault; attempted assault; threat in person; threat by phone, written or online; verbal abuse; sexual harassment by the public; weapon displayed; stage or withdrawal without contact) | Yes | Member |
| Source | Pick list (patient; family or companion; bystander or crowd; occupant; unknown person; other agency personnel; other) | Yes | Member |
| Weapons involved | Pick list (none; edged; blunt or improvised; firearm; dog; vehicle; other) and description | Yes | Member |
| Was a caution flag read by dispatch before arrival? | Yes / No / No flag existed | Yes | Member |
| Did the crew stage? | Yes / No / Not applicable | Yes | Member |
| If proceeded without police “scene safe”, reason | Text | Yes if applicable | Officer |
| Exit word or duress function used? | Pick list (exit word; duress; both; neither) | Yes | Member |
| Police requested and attended? | Yes / No; time requested; time on scene | Yes | Member |
| Police file number | Text | Yes if assault | Officer |
| Members involved (reporter plus crew, by ID) | List | Yes | Member |
| Injuries | Pick list (none; first aid; medical aid; lost time; psychological) and description | Yes | Member |
| Body fluid or sharps exposure during the incident? | Yes / No; link to the exposure report | Yes | Member |
| What happened (facts, in order, no opinions) | Long text | Yes | Member |
| What the member did and what helped | Long text | Yes | Member |
| Part B: officer | |||
| Debrief held (date, time, who attended) | Date-time; list by role | Yes | Officer |
| Member advised to consult a health professional | Yes / date | Yes | Officer |
| Peer support and EFAP offered; accepted (consent to share) | Yes / No; Yes / No / Declined | Yes | Officer |
| Member stood down or modified for the rest of the shift? | Yes / No | Yes | Officer |
| Workers’ compensation report required? Submitted (date)? | Yes / No; date | Yes if injury | Officer with HSO |
| Caution flag requested for the address or person | Yes / No; date requested | Yes | Officer |
| Officer’s observations on conditions (dispatch information, response times, staffing, lighting, equipment) | Long text | Yes | Officer |
| Part C: HSO | |||
| Received and reviewed (date) | Date | Yes | HSO |
| Learning triage tier assigned (Tier 1 AAR; Tier 2 PIA; Tier 3) | Pick list | Yes | Triage group |
| Corrective Action Register entry (number, owner, due date) | Text | Yes if any | HSO |
| JOHSC notified (date; anonymized) | Date | Yes | HSO |
| Police outcome, if known | Text | No | HSO |
| Part D: reply to the reporter | |||
| Preventive action taken (what changed, for whom, by when) | Long text | Yes | HSO or program manager |
| Date reply sent to the reporter | Date | Yes | HSO |
| Reporter acknowledgment | Signature or electronic | Yes | Member |
- Parts A to C are held in {{Records system}} under the program; Part D is sent to the member and filed with the report.
- Injuries also generate the injury report under Policy - Incident, Injury, Exposure and Near-Miss Reporting and Investigation; body fluid exposure generates Form - Body Fluid Exposure Report and Post-Exposure Checklist.
- Retention: 10 years, or service plus 10 years where an injury is recorded.
- Quarterly export by type, location type and call type feeds the program’s indicator worksheet.
This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.
| Topic | What to check in your jurisdiction | Page |
|---|---|---|
| Workplace Violence | Whether the workplace violence regulation applies to fire departments, and its duties to report, investigate and reply in writing to the person who reported, with any deadlines (Parts A to D) | J26 Workplace Violence |