Violence and Harassment Audit and Questionnaire Risk Assesment

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Associate Interviewed

• Location
  Address

Verbal Abuse and Bullying

• Have you experienced verbal abuse (e.g., swearing, insults, teasing, or bullying) while an employee of this company?

  Yes

  No

  N/A

• If yes, did you report the incident(s)?

  Yes

  No

  N/A

• If yes, how did you report the incident?

  Verbally

  In Writing

• What was the relationship of the abuser to you?

  Public (Visitor to Site)

  Co-Worker

  Supervisor or Manager

  Other

• Have you experienced verbal or written threats (e.g., “If you don’t get off my back, you’ll regret it.”) while an employee of this company?

  Yes

  No

  N/A

• If yes, did you report the incident(s)?

  Yes

  No

  N/A

• If yes, how did you report the incident?

  Verbally

  In Writing

• What was the relationship of the abuser to you?

  Public (Visitor to Site)

  Co-Worker

  Supervisor or Manager

  Other

Workplace Environment

• Do you ever work alone or with a small number of associates?

  Yes

  No

  N/A

• Do you have any means to contact someone in the event of an emergency while working in these conditions?

  Compliant

  Non-Compliant

  N/A

• Do you arrive to work early in the morning or late at night?

  Safe

  At Risk

  N/A

• Is there lighting at door ways you enter and parking lots used?

  Safe

  At Risk

  N/A

• Are you concerned about work rage on the job?

  Yes

  No

  N/A

• What is the source of your concern?

• Do you believe that work rage in your workplace is a:

  Low to No Risk

  Moderate Risk

  High Risk

  N/A

• Why do you feel this way?

• Why do you feel this way?