The Consortium Against Responder Violence in NC (CARVNC) is collecting information on both actual and near-miss assault events involving emergency services workers. THIS IS A PROBLEM that is under-reported. Your voluntary completion of this form will assist our development of best practices and track the number, type, and kind of events. YOU MAY COMPLETE THIS FORM WITHOUT A FOLLOW UP (Anonymously) - we think the details of these events are important and we offer an opportunity for a follow up at the end of the form. PLEASE NO PHI / HIPAA PROTECTED INFORMATION.

Date and Time Reported
04/22/2021 21:35

Agency Type

Incident Type

Date of Event

Incident County

Primary Agency (Optional)

Your Role on the Call

Who did the assault or near miss?

If Other, please specify:

Where did the event occur?

If Other, please specify:

Describe what happened

Method of non-Physical Assault (Optional)

If Other, please specify:

Was a Weapon present?

Method of Physical Assault (Optional)

If Other, please specify:

Physical Injury Received (Optional)

If Other, please specify:

How Serious was your Injury? (No injury, Minor, ER evaluation - Describe)

Did you report this event to your employer?

If Other, please specify:

Was Law Enforcement

If Other, please specify:

Any additional information you would like to share? (Short Answer Text or "NONE")

Can one of our workplace violence project investigators follow up with you? (Optional)

What is the best phone number to contact you in the next 72 hours? (Optional)

What is the best TIME range to contact you in the next 72 hours? (Give a time range - i.e, 0800 to 1200 or anytime after 6PM etc) (Optional)

Provide an Email Address for our Follow Up (Optional)