Share a Concern

As part of a commitment to community safety, this form should be used to share a concern regarding an actual or potential workplace violence risk and any employee, friend/family member, customer, or other individual involved. We follow a strict no-retaliation policy and are committed to ensuring a safe workplace. We want to hear about any situation or behavior that raises a risk to anyone’s personal, physical, or emotional well-being.

When in doubt, fill this out. We would much rather receive a concern that we are already aware of or that doesn’t have violence potential than have an employee skip filling out this form and end up missing something we could have acted on.

Your company*

Date and Time of Incident*

Location

Facility Safety Concern

Please provide a detailed description of the concern.

Behavioral Safety Concern

Those involved (please provide full names when possible):

Please check any behaviors that concern you about the situation, employee, or person(s) involved.

Environmental Circumstances:

Death of a loved one or pet

Loss of dating or intimate relationship

Removed from shift, activity, or company event

Pending suspension, police charges, or court involvement

Medical trauma or injury

Unsafe use of a machine or other risky, on-site behavior

Involved in bullying or teasing behavior

Financial insecurity:

Food insecurity

Housing insecurity

Victim of crime or harm

Anger/Aggression:

Disturbing written material or drawings

Threats to hurt another person

Insulting, profane, or aggressive language

Preoccupation or discussion about ammunition or weapons

Showing a weapon or prohibited item at the workplace

Hostility or angry outbursts

Sexual aggression, verbal threat, or physical threat

Concerning Behaviors:

Intense sadness, tearfulness, or expressions of dread

Excessive absences from work or during shifts

Extreme withdrawal and social isolation

Ongoing arguments with other employees

Unusual or odd behavior such as talking to self or strange dress/mannerisms

Suicidal remarks, thoughts, or actions

Self-harming or cutting behaviors

Preoccupation with death and dying

Alcohol or other drug abuse/concern

Please describe the behaviors that have prompted you to share your concerns. Use as much detail as possible, including dates for any specific incidents. If you did not witness the behavior first-hand, please share how you learned of this information.

How long has the behavior been going on?

Have you spoken to or corresponded with anyone about your concern? If yes, who?

Have you told the person that you will be submitting this referral?

Yes

Please share any reports, emails, videos, text messages, or recordings related to the concern.

I understand that referrals from this form will be received during regular business hours (Monday – Friday, 8:00 a.m. – 5:00 p.m.) and are not monitored after hours, on weekends, or during official holidays. I understand that if there is an immediate risk of harm to self or others, I should contact on-site security or the local police before submitting this form.

Your name and job title (optional):

Are you comfortable with us letting those involved know you shared this concern?

Yes