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THREAT ASSESSMENT TEAM
A Threat Assessment Team will be established and part of their duties will be to assess the vulnerability to workplace violence at our establishment and reach agreement on preventive actions to be taken. They
will be responsible for auditing our overall Workplace Violence Program.
The Threat Assessment Team will consist of:
Name:_________________________ Title:_____________________Phone:________
Name:_________________________ Title:_____________________Phone:________
Name:_________________________ Title:_____________________Phone:________
Name:_________________________ Title:_____________________Phone:________
Name:_________________________ Title:_____________________Phone:________
Name:_________________________ Title:_____________________Phone:________
Name:_________________________ Title:_____________________Phone:________
The team will develop employee training programs in violence prevention and plan for responding to acts of violence. They will
communicate this plan internally to all employees. The Threat Assessment
Team will begin its work by reviewing previous incidents of violence at
our workplace. They will analyze and review existing records identifying
patterns that may indicate causes and severity of assault incidents and
identify changes necessary to correct these hazard. These records include
but are not limited to, report logs, past incident reports, medical
records, insurance records, workers compensation records, police reports, accident investigations, training records, grievances, minutes of
meetings, etc. The team will communicate with similar local businesses
and trade associates concerning their experiences with workplace violence.
Additionally, they will inspect the workplace and evaluate the work tasks of all employees to determine the presence of hazards, conditions,
operations and other situations with might place our workers at risk of
occupational assault incidents. Employees will be surveyed to identify the
potential for violent incidents and to identify or confirm the need for
improved security measures. These surveys shall be reviewed, updated and
distributed as needed or at least once within a two year period.
Periodic inspections to identify and evaluate workplace security hazards and threats of workplace violence will be performed by the following representatives of the Assessment Team, in the following areas
of our workplace:
Representative: ________________________ Area ____________________
Representative: ________________________ Area ____________________
Representative: ________________________ Area ____________________
Periodic inspections will be performed according to the following schedule:
___________________________________________________________________________
Frequency (Daily, weekly, monthly, etc.)
HAZARD ASSESSMENT
On [Date], the Threat Assessment Team completed the hazard assessment. This consisted of a records review, inspection of the workaday and employee survey.
Records Review - The Threat Assessment Team reviewed the following records:
____ Report logs for the last three years
____ Incident reports
____ Records of or information compiled for recording of assault incidents or near assault incidents
____ Insurance records
____ Police reports
____ Accident investigations
____ Training records
____ Grievances
____ Other relevant records or information: _____________________
____________________________________________________________
From these records, we have identified the following issues that need to be addressed:
*
*
*
WORKPLACE SECURITY ANALYSIS
Inspection - The Threat Assessment Team inspected the workplace
on [Date]. From this inspection the following issues have been
identified:
*
*
*
Review of Tasks - The Threat Assessment Team also reviewed the work tasks of our employees to determine the presence of hazards,
conditions, operations and situations which might place workers at risk of
occupational assault incidents. The following factors were considered:
* Exchange of money with the public
* Working alone or in small numbers
* Working late at night or early in the morning hours
* Working in a high crime area
* Guarding valuable property or possessions
* Working in community settings
* Staffing levels
From this analysis, the following issues have been identified:
*
*
*
WORKPLACE SURVEY
Under the direction of the Threat Assessment Team, we distributed a survey among all of our employees to identify any additional issues that
were not noted in the initial stages of the hazard assessment.
From that survey, the following issues have been identified:
*
*
*
WORKPLACE HAZARD CONTROL AND PREVENTION
In order to reduce the risk of workplace violence, the following measures have been recommended:
Engineering Controls and Building and Work Area Design
*
*
*
Management has instituted the following as a result of the workplace security inspection and recommendations made by the Threat Assessment
Team:
*
*
*
These changes were completed on [Date].
Policies and Procedures developed as a result of the Threat Assessment Team's recommendations:
*
*
*
TRAINING AND EDUCATION
Training for all employees, including managers and supervisors, was given on [Date]. This training will be repeated every two years.
Training included:
* a review and definition of workplace violence;
* a full explanation and full description of our program (all employees were given a copy of this program at orientation);
* instructions on how to report all incidents including threats and verbal abuse;
* methods of recognizing and responding to workplace security hazards;
* training on how to identify potential workplace security hazards (such as no lights in parking lot while leaving late at night, unknown person loitering outside the building, etc.)
* review of measures that have been instituted in this organization to prevent workplace violence including:
* use of security equipment and procedures;
* how to attempt to diffuse hostile or threatening situations;
* how to summon assistance in case of an emergency or hostage situation;
* post-incident procedures, including medical follow-up and the availability of counseling and referral.
Additional specialized training was given to:
* Name, Department, Job Title
* Name, Department, Job Title
* Name, Department, Job Title
This training was conducted by _______________________________ on [Date] and will be repeated every two years.
Trainers will be qualified and knowledgeable. Our trainers are professionals [list type of certification]. At the end of each
training session, employees will be asked to evaluate the session and make
suggestions on how to improve the training.
All training records will be filed with _____________________.
Workplace Violence Prevention training will be given to new employees as part of their orientation.
A general review of this program will be conducted every two years. Our training program will be updated to reflect changes in our Workplace
Prevention Program.
INCIDENT REPORTING AND INVESTIGATION
All incidents must be reported within [Time]. An "Incident Report Form" will be completed for all incidents. One copy will be
forwarded to the Threat Assessment Team for their review and a copy will
be filed with [Job Title].
Each incident will be evaluated by the Threat Assessment Team. The team will discuss the causes of the incident and will make recommendations
on how to revise the program to prevent similar incidents from occurring.
All revisions of the Program will be put into writing and made available to all employees.
RECORD KEEPING
We will maintain an accurate record of all workplace violence
incidents. All incident report forms will be kept for a minimum of [Time], or for the time specified in the Statute of Limitations for
our local jurisdiction.
Any injury which requires more than first aid, is a lost-time injury, requires modified duty, or causes loss of consciousness, will be recorded
on the Report log. Doctors' reports and supervisors' reports will be kept of each recorded incident, if applicable.
Incidents of abuse, verbal attack, or aggressive behavior which may be threatening to the employee, but not resulting in injury, will be
recorded. These records will be evaluated on a regular basis by the
Threat Assessment Team.
Minutes of the Threat Assessment Team meetings shall be kept for [Time].
Records of training program contents, and the sign-in sheets of all attendees, shall be kept for [Time]. Qualifications of the
trainers shall be maintained along with the training records.
COMPLETED WPVP PROGRAM (EXAMPLE) ABC COMPANIES WPVP PROGRAM POLICY STATEMENT
JANUARY 1, 1996
Our establishment, ABC COMPANY, is concerned and committed to our employees' safety and health. We refuse to tolerate violence in the workplace and will make every effort to prevent violent incidents from
occurring by implementing a Workplace Violence Prevention Program
(WPVP). We will provide adequate authority and budgetary resources to responsible
parties so that our goals and responsibilities can be met.
All managers and supervisors are responsible for implementing and maintaining our WPVP Program. We encourage employee participation in designing and implementing our program. We require prompt and accurate
reporting of all violent incidents whether or not physical injury has
occurred. We will not discriminate against victims of workplace violence.
A copy of this Policy Statement and our WPVP Program is readily available to all employees from each manager and supervisor.
Our program ensures that all employees, including supervisors and managers, adhere to work practices that are designed to make the workplace more secure, and do not engage in verbal threats or physical actions which
create a security hazard for others in the workplace.
All employees, including managers and supervisors, are responsible for using safe work practices, for following all directives, policies and
procedures, and for assisting in maintaining a safe and secure work
environment.
The management of our establishment is responsible for ensuring that all safety and health policies and procedures involving workplace security
are clearly communicated and understood by all employees. Managers and
supervisors are expected to enforce the rules fairly and uniformly.
Our Program will be reviewed and updated annually.
WORKPLACE VIOLENCE PREVENTION PROGRAM
THREAT ASSESSMENT TEAM
A Threat Assessment Team will be established and part of their duties will be to assess the vulnerability to workplace violence at our establishment and reach agreement on preventive actions to be taken. They
will be responsible for auditing our overall Workplace Violence Program.
The Threat Assessment Team will consist of:
Name: John Smith Title: Vice President Phone: 555-1212
Name: Jane Doe Title: Operations Phone: 555-1234
Name: Frank Kras Title: Shop Steward Phone: 555-1233
Name: James Brown Title: Security Phone: 555-1456
Name: Susan Dean Title: Treasurer Phone: 555-1567
Name: Tom Jones Title: Legal Counsel Phone: 555-1678
Name: Sally Field Title: Personnel Phone: 555-1789
The team will develop employee training programs in violence prevention and plan for responding to acts of violence. They will
communicate this plan internally to all employees.
The Threat Assessment Team will begin its work by reviewing previous incidents of violence at our workplace. They will analyze and review
existing records identifying patterns that may indicate causes and
severity of assault incidents and identify changes necessary to correct
these hazards. These records include but are not limited to,
Report logs, past incident reports, medical records, insurance records, workers compensation records, police reports, accident investigations, training records, grievances, minutes of meetings, etc. The team will communicate
with similar local businesses and trade associates concerning their experiences with workplace violence.
Additionally, they will inspect the workplace and evaluate the work tasks of all employees to determine the presence of hazards, conditions, operations and other situations with might place our workers at risk of
occupational assault incidents. Employees will be surveyed to identify the potential for violent incidents and to identify or confirm the need for improved security measures. These surveys shall be reviewed, updated
and distributed as needed or at least once within a two year period.
Periodic inspections to identify and evaluate workplace security hazards and threats of workplace violence will be performed by the
following representatives of the Assessment Team, in the following areas
of our workplace:
Representative: John Smith Area General Office
Representative: Frank Kras Area Shop and Lab
Representative: Jane Doe Area Reception & Sales
Periodic inspections will be performed according to the following schedule:
First Monday of Every Month
-------------------------------------------
Frequency (Daily, weekly, monthly, etc.)
HAZARD ASSESSMENT
On September 5, 1995, the Threat Assessment Team completed the hazard assessment. This consisted of a records review, inspection of the worksite and employee survey.
Records Review - The Threat Assessment Team reviewed the following records:
__X__ Report logs for the last three years
__X__ Incident reports
__X__ Records of or information compiled for recording of assault incidents or near assault incidents
__X__ Insurance records
_____ Police reports
_____ Accident investigations
_____ Training records
__X__ Grievances
__X__ Other relevant records or information: Workers' Compensation records.
From these records, we have identified the following issues that need to be addressed:
* employees have been assaulted by irate clients;
* employees have been assaulted while traveling alone;
* there have been several incidents of assault and harassment among employees.
WORKPLACE SECURITY ANALYSIS
Inspection - The Threat Assessment Team inspected the workplace on
July 31, 1995.
From this inspection the following issues have been identified:
* access to the building is not controlled; and it is not limited to any of the offices on the four floors that we occupy. There
have been problems with non-employees entering private work areas;
* doors to the restrooms are not kept locked;
* lighting in the parking lot is inadequate;
* in client service area, desks are situated in a way that make it necessary for employee to walk past the client in order to leave
area. There are many objects on top of desks that could be used
as weapons (i.e., scissors, stapler, file rack, etc.).
Review of Tasks - The Threat Assessment Team also reviewed the work tasks of our employees to determine the presence of hazards,
conditions, operations and situations which might place workers at risk of
occupational assault incidents. The following factors were considered:
* Exchange of money with the public
* Working alone or in small numbers
* Working late at night or early in the morning hours
* Working in a high crime area
* Guarding valuable property or possessions
* Working in community settings
* Staffing levels
From this analysis, the following issues have been identified:
* employees in client service area exchange money with clients;
* there are several employees who work very late hours or come in very early in the morning in the shop and lab areas.
WORKPLACE SURVEY
Under the direction of the Threat Assessment Team, we distributed a survey among all of our employees to identify any additional issues that were not noted in the initial stages of the hazard assessment. From that
survey, the following issues have been identified:
* employees who work in the field have experienced threats of violence on several occasions, and there have been several near
miss incidents. Employees noted that they were unsure of how to
handle the situation and that they are often afraid to travel by themselves to areas they perceive are dangerous;
* employees who work directly with clients in the office have also experienced threats, both verbal and physical, from some of the clients.
WORKPLACE HAZARD CONTROL AND PREVENTION
In order to reduce the risk of workplace violence, the following measures have been recommended:
Engineering Controls and Building and Work Area Design
* Employees who have client contact in the facility, will have their work areas designed to ensure that they are protected from possible threats from their clients.
* Changes to be completed as soon as possible and include:
* arranging desks and chairs to prevent entrapment of the employees;
* removing items from the top of desks, such as scissors, staplers, etc. that can be used as a weapon;
* installing panic buttons to assist employees when they are threatened by clients. The buttons can be
activated by one's foot. The signal will be transmitted to a supervisor's desk, as well as the
security desk, which is always staffed.
Management has instituted the following as a result of the workplace security inspection and recommendations made by the Threat Assessment
Team:
* Installation of plexi-glass payment window for employees who handle money and need to take payments from clients
(number of employees who take money will be strictly limited);
* Adequate lighting systems installed for indoor building areas as well as areas around the outside of the facility
and in the parking areas. The lighting systems will be maintained on a regular basis to ensure safety to all
employees;
* Locks installed on restroom doors and keys will be given to each department. Restroom doors are to be kept locked
at all times. Supervisors will ensure that the keys are returned to ensure continued security for employees in
their areas.
* Installation of panic buttons in employees work areas.
* Memorandum to all employees requesting that they remove any items from their desks that can be used as a weapon,
such as scissors, staplers, etc.
These changes were completed by January 1, 1996.
Policies and Procedures developed as a result of the Threat Assessment Team recommendations:
* Employees who are required to work in the field and who feel that the situation is unsafe should travel in "buddy" systems
or with an escort from their supervisor.
* Employees who work in the field will report to their supervisor periodically throughout the day. They will be
provided with a personal beeper or cellular phone, which will allow them to contact assistance should an incident occur.
* Access to the building will be controlled. All employees have been given a name badge which is to be worn at all times. If employees come in early, or are working past 7:30 p.m., they
must enter and exit through the main entrance.
* Visitors will be required to sign in at the front desk. All clients must enter through the main entrance to gain access.
TRAINING AND EDUCATION
Training for all employees, including managers and supervisors, was
given on September 01, xxxx. This training will be repeated every two years.
Training included:
* a review and definition of workplace violence;
* a full explanation and full description of our program (all employees were given a copy of this program at orientation);
* instructions on how to report all incidents including threats and verbal abuse;
* methods of recognizing and responding to workplace security hazards;
* training on how to identify potential workplace security hazards (such as no lights in parking lot while leaving late at
night, unknown person loitering outside the building, etc.)
* review of measures that have been instituted in this organization to prevent workplace violence including:
* use of security equipment and procedures;
* how to attempt to diffuse hostile or threatening situations;
* how to summon assistance in case of an emergency or hostage situation;
* post-incident procedures, including medical follow-up and the availability of counseling and referral.
Additional specialized training was given to:
* Employees who work in the field;
* Employees who handle money with clients;
* Employees who work after hours or come in early.
Specialized training included:
* Personal safety;
* Importance of the buddy system;
* Recognizing unsafe situations and how to handle them during off hours.
This training was conducted by in-house staff, with assistance from the local police department on October 1, 1995 and will be repeated every
two years.
Trainers were qualified and knowledgeable. Our trainers are professionals certified by the Society of Industrial Security.
At the end of each training session, employees are asked to evaluate the session and make suggestions on how to improve the training.
All training records are filed with the Human Resource Department/Personnel Department.
Workplace Violence Prevention training will be given to new employees as part of their orientation.
A general review of this program will be conducted every two years. Our training program will be updated to reflect changes in our Workplace
Prevention Program.
INCIDENT REPORTING AND INVESTIGATION
All incidents must be reported within Four (4) hours. An "Incident Report Form" will be completed for all incidents. One copy will
be forwarded to the Threat Assessment Team for their review and a copy
will be filed with the Human Resource/Personnel Department.
Each incident will be evaluated by the Threat Assessment Team. The team will discuss the causes of the incident and will make recommendations
on how to revise the program to prevent similar incidents from occurring.
All revisions of the Program will be put into writing and made available
to all employees.
RECORD KEEPING
We will maintain an accurate record of all workplace violence incidents. All incident report forms will be kept for a minimum of
seven (7) years, or for the time specified in the Statute of
Limitations for our local jurisdiction.
Any injury which requires more than first aid, is a lost-time injury, requires modified duty, or causes loss of consciousness, will be recorded
on the Report log. Doctors' reports and supervisors' reports will be kept of each recorded incident, if applicable.
Incidents of abuse, verbal attack, or aggressive behavior which may be threatening to the employee, but not resulting in injury, will be
recorded. These records will be evaluated on a regular basis by the
Threat Assessment Team.
Minutes of the Threat Assessment Team meetings shall be kept for three (3) years.
Records of training program contents, and the sign-in sheets of all attendees, shall be kept for five (5) years. Qualifications of the
trainers shall be maintained along with the training records.
SAMPLE
SELF INSPECTION SECURITY CHECKLIST
Facility: ________________________________________________________________
Inspector: _______________________________________________________________
Date of Inspection: ______________________________________________________
1. Security Control Plan: ____Yes ____No
If yes, does it contain:
(A) Policy Statement ____Yes ____No
(B) Review of Employee Incident Exposure ____Yes ____No
(C) Methods of Control ____Yes ____No
If yes, does it include:
Engineering ____Yes ____No
Work Practice ____Yes ____No
Training ____Yes ____No
Reporting Procedures ____Yes ____No
Recordkeeping ____Yes ____No
Counseling ____Yes ____No
(D) Evaluation of Incidents ____Yes ____No
(E) Floor Plan ____Yes ____No
(F) Protection of Assets ____Yes ____No
(G) Computer Security ____Yes ____No
(H) Plan Accessible to All Employees ____Yes ____No
(I) Plan Reviewed and Updated Annually ____Yes ____No
(J) Plan Reviewed and Updated When Tasks
Added or Changed ____Yes ____No
2. Policy Statement by Employer ____Yes ____No
3. Work Areas Evaluated by Employer ____Yes ____No
If yes, how often? ________________
4. Engineering Controls ____Yes ____No
If yes, does it include:
(A) Mirrors to see around corners and in
blind spots ____Yes ____No
(B) Landscaping to provide unobstructed
view of the workplace ____Yes ____No
(C)"Fishbowl effect" to allow unobstructed
view of the interior ____Yes ____No
(D) Limiting the posting of sale signs on
windows ____Yes ____No
(E) Adequate lighting in and around the
workplace ____Yes ____No
(F) Parking lot well lighted ____Yes ____No
(G) Door Control(s) ____Yes ____No
(H) Panic Button(s) ____Yes ____No
(I) Door Detector(s) ____Yes ____No
(J) Closed Circuit TV ____Yes ____No
(K) Stationary Metal Detector ____Yes ____No
(L) Sound Detection ____Yes ____No
(M) Intrusion Detection System ____Yes ____No
(N) Intrusion Panel ____Yes ____No
(O) Monitor(s) ____Yes ____No
(P) Video Tape Recorder ____Yes ____No
(Q) Switcher ____Yes ____No
(R) Hand Held Metal Detector ____Yes ____No
(S) Hand held video camera ____Yes ____No
(T) Personnel traps ("Sally Traps") ____Yes ____No
(U) Other ______________________________ ____Yes ____No
5. Structural Modifications Plexiglas, glass guard, wire glass, partitions, etc. ____Yes ____No
If yes, comment:____________________________________________
____________________________________________________________
6. Security Guards ____Yes ____No
(A) If yes, are there an appropriate number for the site? ____Yes ____No
(B) Are they knowledgeable of the company WPVP Policy? ____Yes ____No
(C) Indicate if they are:
______Contract Guards (1)
______In-house Employees (2)
(D) At Entrance(s) ____Yes ____No
(E) Building Patrol ____Yes ____No
(F) Guards provided with communication? ____Yes ____No
If yes, indicate what type:_________________________________
____________________________________________________________
(G) Guards receive training on Workplace Violence
situations? ____Yes ____No
Comments:___________________________________________________
____________________________________________________________
7. Work Practice Controls ____Yes ____No
If yes, indicate:
(A) Desks Clear of Objects which may become Missiles ____Yes ____No
(B) Unobstructed Office Exits ____Yes ____No
(C) Vacant (Bare) Cubicles Available ____Yes ____No
(D) Reception Area Available ____Yes ____No
(E) Visitor/Client Sign In/Out ____Yes ____No
(F) Visitor(s)/Client(s) Escorted ____Yes ____No
(G) Barriers to Separate Clients from
Work Area ____Yes ____No
(H) One Entrance Used ____Yes ____No
(I) Separate Interview Area(s) ____Yes ____No
(J) I.D. Badges Used ____Yes ____No
(K) Emergency Numbers Posted By Phones ____Yes ____No
(L) Internal Phone System ____Yes ____No
If yes, indicate:
Does it Use 120 VAC Building Lines ____Yes ____No
Does it Use Phone Lines ____Yes ____No
(M) Internal Procedures for Conflict
(Problem) Situations ____Yes ____No
(N) Procedures for employee dismissal ____Yes ____No
(O) Limit Spouse & Family Visits to
Designated Areas ____Yes ____No
(P) Key Control Procedures ____Yes ____No
(Q) Access Control to the Workplace ____Yes ____No
(R) Objects which may become Missiles
Removed from Area ____Yes ____No
(S) Parking Prohibited in Fire Zones ____Yes ____No
Other:______________________________________________________
____________________________________________________________
7a. Off Premises Work Practice Controls (For staff who work away from a fixed workplace,
such as: social services, real estate, utilities, policy/fire/sanitation, taxi/limo, construction,
sales/delivery, messengers, and others.)
(A) Trained in hazardous situation avoidance ____Yes ____No
(B) Briefed about areas where they work ____Yes ____No
(C) Have reviewed past incidents by type and area ____Yes ____No
(D) Know directions and routes for day's schedule ____Yes ____No
(E) Previewed client/case histories ____Yes ____No
(F) Left an itinerary with contact information ____Yes ____No
(G) Have periodic check-in procedures ____Yes ____No
(H) After hours contact procedures ____Yes ____No
(I) Partnering arrangements if deemed necessary ____Yes ____No
(J) Know how to control/defuse potentially violent situations ____Yes ____No
(K) Supplied with personal alarm/cellular phone/radio ____Yes ____No
(L) Limit visible clues of carrying money/valuables ____Yes ____No
(M) Carry forms to record incidents by area ____Yes ____No
(N) Know procedures if involved in incident ____Yes ____No
(see also Training Section)
8. Training Conducted ____Yes ____No
If yes, is it:
(A) Prior to Initial Assignment ____Yes ____No
(B) At Least Annually Thereafter ____Yes ____No
(C) Does it Include:
Components of security control plan ____Yes ____No
Engineering and Workplace Controls Instituted at Workplace ____Yes ____No
Techniques to Use in Potentially Volatile Situations ____Yes ____No
How to Anticipate/Read Behavior ____Yes ____No
Procedures to Follow After an Incident ____Yes ____No
Periodic Refresher for On-Site Procedures ____Yes ____No
Recognizing Abuse/Paraphernalia ____Yes ____No
Opportunity for Q and A with Instructor ____Yes ____No
On hazards unique to job tasks ____Yes ____No
9. Written Training Records Kept ____Yes ____No
10. Are Incidents Reported ____Yes ____No
If yes, are they:
(A) Reported in Written Form ____Yes ____No
(B) First Report of Injury Form (If
Employee Loses Time) ____Yes ____No
11. Incidents Evaluated ____Yes ____No
(A) EAP Counseling Offered ____Yes ____No
(B) Other Action (Reporting Requirements, suggestions, reporting to local authorities,
etc.)_________________
________________________________________________________
(C) Are Steps Taken to Prevent Recurrence? ____Yes ____No
12. Floor Plans Posted Showing Exits, Entrances, Location of Security Equipment, Etc. ____Yes ____No
If yes, does it:
(A) Include an Emergency Action Plan, Evacuation Plan, and/or a Disaster Contingency Plan? ____Yes ____No
13. Do Employees Feel Safe ____Yes ____No
(A) Have employees been surveyed to find out their concerns ____Yes ____No
(B) Has the employer utilized the crime prevention services and/or lectures provided by the local or State police? ____Yes ____No
Comments:___________________________________________________
____________________________________________________________
General Comments/Recommendations:___________________________
____________________________________________________________
SAMPLE
INCIDENT REPORT FORM
1. VICTIMS NAME:________________________ JOB TITLE:_______________
2. VICTIMS ADDRESS:_______________________________________________
3. HOME PHONE NUMBER:___________ WORK PHONE NUMBER:_______________
4. EMPLOYERS NAME AND ADDRESS:____________________________________
5. DEPARTMENT/SECTION:____________________________________________
6. VICTIMS SOCIAL SECURITY NUMBER:________________________________
7. INCIDENT DATE__________________________________________________
8. INCIDENT TIME:_________________________________________________
9. INCIDENT LOCATION:_____________________________________________
10. WORK LOCATION (if different):_________________________________
11. TYPE OF INCIDENT: (circle one): Assault, Robbery, Harassment, Disorderly Conduct, Sex Offense, Other. (Please Specify)
_________________________________________________________________
(See attached - DEFINITION OF INCIDENTS WORKSHEET)
12. WERE YOU INJURED: (circle): Yes No
If yes, please specify your injuries and the location of any treatment:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
13. DID POLICE RESPOND TO INCIDENT: Yes No
14. WHAT POLICE DEPARTMENT:______________________________________
15. POLICE REPORT FILED: Yes No
REPORT NUMBER: __________
16. WAS YOUR SUPERVISOR NOTIFIED: Yes No
17. SUPERVISORS NAME:____________________________________________
18. WAS THE LOCAL UNION/EMPLOYEE REPRESENTATIVE NOTIFIED: Yes/no
Who should be notified_____________________________________
19. WAS ANY ACTION TAKEN BY EMPLOYER: (specify)__________________
_________________________________________________________________
20. ASSAILANT/PERPETRATOR: (circle one): Intruder, Customer, Patient, Resident, Client, Visitor, Student, Co-Worker, Former,
Employee, Supervisor, Family/Friend, Other, (specify):___________
_________________________________________________________________
21. ASSAILANT/PERPETRATOR - NAME/ADDRESS/AGE (if known):_________
_________________________________________________________________
_________________________________________________________________
22. PLEASE BRIEFLY DESCRIBE THE INCIDENT:________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
23. INCIDENT DISPOSITION: (Circle all that apply): No action taken, Arrest, Warning, Suspension, Reprimand, Other:___________________
_________________________________________________________________
24. DID THE INCIDENT INVOLVE A WEAPON: Yes/no Specify____________
_________________________________________________________________
25. DID YOU LOSE ANY WORK DAYS: Yes No
Specify __________________________________________________________
26. WERE YOU SINGLED OUT OR WAS THE VIOLENCE DIRECTED AT MORE THAN ONE INDIVIDUAL: _________________________________________________
27. WERE YOU ALONE WHEN THE INCIDENT OCCURRED:___________________
28. DID YOU HAVE ANY REASON TO BELIEVE THAT AN INCIDENT MIGHT OCCUR: Yes No
Why:_____________________________________________________________
29. HAS THIS TYPE OR SIMILAR INCIDENT(S) HAPPENED TO YOU OR YOUR CO-WORKERS: Yes No
Specify:_________________________________________________________
30. HAVE YOU HAD ANY COUNSELING OR SUPPORT SINCE THE INCIDENT: Yes No
Specify:_________________________________________________________
31. WHAT DO YOU FEEL CAN BE DONE IN THE FUTURE TO AVOID SUCH AN INCIDENT:
________________________________________________________
32. WAS THIS ASSAILANT INVOLVED IN PREVIOUS INCIDENTS:___________
_________________________________________________________________
33. ARE THERE ANY MEASURES IN PLACE TO PREVENT SIMILAR INCIDENTS:
Yes No
Specify:_________________________________________________________
34. HAS CORRECTIVE ACTION BEEN TAKEN:
Specify:_________________________________________________________
35. COMMENTS:____________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
SAMPLE
EMPLOYEE SECURITY SURVEY
This survey will help detect Security Problems in your building or at an alternate worksite.
Please fill out this form, get your co-workers to fill it out and review it to see where the potential for major security problems lie.
NAME:____________________________________________________________
WORK LOCATION:___________________________________________________
(IN BUILDING OR ALTERNATE WORKSITE)
1. Do either of these two conditions exist in your building or at your alternate work site?
___ Work alone during working hours.
___ No notification given to anyone when you finish work.
Are these conditions a problem? If so when, please describe. (For example, Mondays, evening, daylight savings time)
2. Do you have any of the following complaints (that may be associated with causing an unsafe worksite)?
(Check all that apply)
___ Does your work place have a written policy to follow for addressing general problems?
___ Does your work place have a written policy on how to handle a violent client
___ When and how to request the assistance of a co-worker
___ When and how to request the assistance of police
___ What to do about a verbal threat
___ What to do about a threat of violence
___ What to do about harassment
___ Working alone
___ Alarm System(s)
___ Security in and out of building
___ Security in parking lot
___ Have you been assaulted by a co-worker?
___ To your knowledge have incidents of violence ever occurred between your co-workers?
3. Are violence related incidents worse during shift work, on the road or in other situations.
Please specify: __________________________
4. Where in the building or worksite would a violence related incident most likely to occur?
___ lounge ___ exits ___ deliveries ___ private offices
___ parking lot ___ bathroom ___ entrance ___ Other
Other (specify)____________________________
5. Have you ever noticed a situation that could lead to a violent incident?
6. Have you missed work because of a potential violent act(s) committed during your course of employment?
7. Do you receive workplace violence related training or assistance of any kind?
8. Has anything happened recently at your worksite that could have lead to violence?
9. Can you comment about the situation?
10. Has the number of violent clients increased?
DEFINITION OF INCIDENTS
1. ASSAULT:
The intentional use of physical injury, (impairment of physical condition or substantial pain) to another person, with or without a weapon or dangerous instrument.
2. CRIMINAL MISCHIEF:
Intentional or reckless damaging of the property of another person without permission.
3. DISORDERLY CONDUCT:
Intentionally causing public inconvenience, annoyance or alarm or recklessly creating a risk thereof by fighting (without injury) or in violent numinous or threatening behavior or making unreasonable noise, shouting abuse, misbehaving, disturbing an assembly or
meeting or persons or creating hazardous conditions by an act which serves no legitimate purpose.
4. HARASSMENT:
Intentionally striking, shoving or kicking another or subjecting another person to physical contact, or threatening to do the same (without physical injury). ALSO, using abusive or obscene language or following a person in about a public place, or engaging in a course of conduct which alarms or seriously annoys another person.
5. LARCENY:
Wrongful taking, depriving or withholding property from another (no force involved). Victim may or may not be present.
6. MENACING:
Intentionally places or attempts to place another person in fear of imminent serious physical injury.
7. RECKLESS ENDANGERMENT:
Subjecting individuals to danger by recklessly engaging in conduct which creates substantial risk of serious physical injury.
8. ROBBERY:
Forcible stealing of another's property by use of threat of immediate physical force. (Victim is present and aware of theft).
9. SEX OFFENSE:
Public Lewdness: Exposure of sexual organs to others.
Sexual Abuse: Subjecting another to sexual contact without consent.
Sodomy: A deviant sexual act committed as in rape.
Rape: Sexual intercourse without consent.
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