Workplace Violence Prevention Hazard Assessment

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• ----------------------- START HERE -----------------------------

• BEFORE you start answering the survey, please complete the following tasks:

• ⇒ Report information only about the Reporting Site identified on the address label.

• ⇒ Verify the information printed on the cover under Your Company Address and make corrections
  where necessary

• ⇒ Forward this to the person who is most informed about workplace violence prevention in your
  establishment

1 CONTACT INFORMATION — PLEASE PRINT:

• Name of person completing the survey:

• Job title:

• Phone number:

• Ext

• Month and day completed:

  Date

2 How many employees are currently employed by your establishment?

• ⇒ Include all paid employees (full-time, part-time, hourly, salaried, temporary, and seasonal).

• NUMBER OF CURRENTEMPLOYEES:

DEFINITION of Workplace Violence

• Please use the following definition of workplace violence to answer the questions in this survey.

  

Section I: Operations

• ► Answer questions for ALL employees including contractors and subcontractors who work for the reporting site

• 3 Which of the following types of security features are provided at your establishment, even if used as needed?

• 3a Electronic Surveillance — Check ALL that apply

  Select No electronic surveillance Intruder/Burglar alarm systems Surveillance cameras Motion detectors Metal detectors X-ray inspection of items brought into workplace (e.g. bags, briefcases, packages) Electronic badge or ID scanners at entrances and exits to building or work areas Employees’ personal alarms Other

  • No electronic surveillance
  • Intruder/Burglar alarm systems
  • Surveillance cameras
  • Motion detectors
  • Metal detectors
  • X-ray inspection of items brought into workplace (e.g. bags, briefcases, packages)
  • Electronic badge or ID scanners at entrances and exits to building or work areas
  • Employees’ personal alarms
  • Other

• Specify

• 3b Security Staff — Check ALL that apply

  Select No security staff Campus or site-specific police Security guards, including contracted Armed Guard dogs Other

  • No security staff
  • Campus or site-specific police
  • Security guards, including contracted
  • Armed
  • Guard dogs
  • Other

• Specify

• 3c Physical Security — Check ALL that apply

  Select No physical security features Limited access (e.g. secured entrances or doors that are kept locked during working hours) Physical barriers or fences between work areas and the public (includes protective barriers in vehicles) Visibility of work areas (e.g. lighting) Cash handling processes (e.g. drop safes) Other_

  • No physical security features
  • Limited access (e.g. secured entrances or doors that are kept locked during working hours)
  • Physical barriers or fences between work areas and the public (includes protective barriers in vehicles)
  • Visibility of work areas (e.g. lighting)
  • Cash handling processes (e.g. drop safes)
  • Other_

• Specify

• 4 Is your establishment open to the general public?

  Yes

  No

• Select ALL of the hours that your establishment is open to the general public.

  Select between 6 a.m. and 5 p.m. Hours between 5 p.m. and 11 p.m. Hours between 11 p.m. and 2 a.m. Hours between 2 a.m. and 6 a.m

  • between 6 a.m. and 5 p.m.
  • Hours between 5 p.m. and 11 p.m.
  • Hours between 11 p.m. and 2 a.m.
  • Hours between 2 a.m. and 6 a.m

• 5 Select ALL of the hours that employees work at your establishment, regardless of whether your establishment is open or closed to the general public during those times.

  Select Hours between 6 a.m. and 5 p.m. Hours between 5 p.m. and 11 p.m. Hours between 11 p.m. and 2 a.m. Hours between 2 a.m. and 6 a.m

  • Hours between 6 a.m. and 5 p.m.
  • Hours between 5 p.m. and 11 p.m.
  • Hours between 11 p.m. and 2 a.m.
  • Hours between 2 a.m. and 6 a.m

• (If 11 p.m. to 2 a.m. and/or 2 a.m. to 6 a.m. are checked) Which of the following procedures are used between 11 p.m. and 6 a.m.? Check ALL that apply

  Select Limited contact with the public (e.g. cash and small items exchanged using a passthrough window) Minimum of two employees working together Limiting the amount of cash on-hand (e.g. drop safes) Escorts to parking areas Employees’ personal alarm systems Security systems (e.g. cameras) Visibility of work areas (e.g. lighting) Other No procedures are used

  • Limited contact with the public (e.g. cash and small items exchanged using a passthrough window)
  • Minimum of two employees working together
  • Limiting the amount of cash on-hand (e.g. drop safes)
  • Escorts to parking areas
  • Employees’ personal alarm systems
  • Security systems (e.g. cameras)
  • Visibility of work areas (e.g. lighting)
  • Other
  • No procedures are used

• Specify

• 6 Which of the following situations apply to employees who work at your establishment? Check ALL that apply.

  Select Working in direct contact with the public Exchanging money with customers Having a mobile workplace (e.g. working out of a vehicle) or delivering passengers, goods, or services (e.g. taxicab, police cruisers, postal route, or takeout food delivery) Working with unstable or volatile persons in health care, social service, or criminal justice settings Working in high crime areas Interaction with unhoused persons Guarding valuable goods or property (e.g. a museum or armored car guard) Working in small numbers (fewer than 5) Working in community-based settings or going door to-door to residences (e.g. home health care, services, child welfare, or meter readers) Other____________________________________ None of the above

  • Working in direct contact with the public
  • Exchanging money with customers
  • Having a mobile workplace (e.g. working out of a vehicle) or delivering passengers, goods, or services (e.g. taxicab, police cruisers, postal route, or takeout food delivery)
  • Working with unstable or volatile persons in health care, social service, or criminal justice settings
  • Working in high crime areas
  • Interaction with unhoused persons
  • Guarding valuable goods or property (e.g. a museum or armored car guard)
  • Working in small numbers (fewer than 5)
  • Working in community-based settings or going door to-door to residences (e.g. home health care, services, child welfare, or meter readers)
  • Other____________________________________
  • None of the above

• Specify

• 7 Do employees at your establishment work alone at any time? Examples include a clerk working alone at a convenience store, a taxicab driver, a social worker making house visits, or a nurse on a ward by him or herself.

  Yes

  No

• Which of the following prevention strategies are used when this happens? Check ALL that apply.

  Select Limited contact with the public (e.g. cash and small items exchanged using a pass-through window) Limited amount of cash on-hand (e.g. drop safes) Escorts to parking areas alarm systems for employees Security systems (e.g. cameras) Visibility of work areas (e.g. lighting) Other_________________________ No prevention strategies are used

  • Limited contact with the public (e.g. cash and small items exchanged using a pass-through window)
  • Limited amount of cash on-hand (e.g. drop safes)
  • Escorts to parking areas
  • alarm systems for employees
  • Security systems (e.g. cameras)
  • Visibility of work areas (e.g. lighting)
  • Other_________________________
  • No prevention strategies are used

• Specify

• 8 Which of the following are your staff, including security staff, authorized to do at your establishment? Check ALL that apply.

  Select Register or check in visitors before entering the office/building Check employees’ badges or IDs before employees enter the office/building Stop entry due to restraining/protective orders Use photographs of persons to screen entry of possible offenders who may resort to violence Screen calls for victims of harassment or domestic violence Have authority to arrest or detain persons for police Have authority to seize weapons Other___________________________________ … None of the above

  • Register or check in visitors before entering the office/building
  • Check employees’ badges or IDs before employees enter the office/building
  • Stop entry due to restraining/protective orders
  • Use photographs of persons to screen entry of possible offenders who may resort to violence
  • Screen calls for victims of harassment or domestic violence
  • Have authority to arrest or detain persons for police
  • Have authority to seize weapons
  • Other___________________________________
  • … None of the above

• 9 Does your establishment have a PROCESS OR METHOD to identify clients, customers, visitors,<br>and/or patients with a history of violence?

  Yes

  No

• 10 Does your establishment have a PROCESS OR METHOD (e.g. background checks, security<br>clearance, employment or personal reference checks) to identify potential employees or current<br>employees with a history of violence

  Yes

  No

• 11 Does your establishment provide additional security arrangements (e.g. panic alarms,<br>workstation barriers) for employees who have been victims of workplace violence?

  Yes

  No

• Which of the following security measures does your establishment provide? Check ALL that apply.

  Select Panic alarms Workstation barriers Relocation to another workplace (e.g. working at a different location) More secure parking places made available Cell phones provided for commute available Enforcement of restraining/protective orders Other

  • Panic alarms
  • Workstation barriers
  • Relocation to another workplace (e.g. working at a different location)
  • More secure parking places made available
  • Cell phones provided for commute available
  • Enforcement of restraining/protective orders
  • Other

• Specify

Section II: Programs and Policies

• ► Answer questions for ALL employees including contractors and subcontractors who
  work for the reporting site.
  

• 12 Does your establishment have a program or policy that includes workplace violence prevention?

  Yes

  No

• Which type of format? Check ALL that apply.

  Select Written program or policy Verbal program or policy

  • Written program or policy
  • Verbal program or policy

• 13 Which of the following situations does your establishment’s workplace violence program or policy address? Check ALL that apply Criminal: when the perpetrator has no legitimate relationship to the business or its employees and is usually committing a crime in conjunction with the violence (e.g. robbery, shoplifting, or trespassing). Customer or Client: when the perpetrator has a legitimate relationship with the business and becomes violent while being served by the business (e.g. customers, clients, patients, students, inmates, or for any other group that the business provides services). Co-Worker: when the perpetrator is an employee, past employee of the business, or contractor who works as a temporary employee on your site and who attacks or threatens another employee. Domestic Violence: when the perpetrator, who has no legitimate relationship to the business (but has a personal relationship with the intended victim), threatens or assaults the employee at the workplace (e.g. family member, boyfriend, or girlfriend).

  Select Criminal Customer or Client: Co-Worker Domestic Violence:

  • Criminal
  • Customer or Client:
  • Co-Worker
  • Domestic Violence:

• 14 Does the program or policy instruct employees about how to report concerns or incidents of<br>workplace violence? <br>

  Yes

  No

• Which of the following reporting methods are included in your establishment’s workplace violence program or policy? Check ALL that apply.

  Select How employees report incidents How supervisors report incidents How to fill out an incident report form How to access an anonymous “800”, toll free, or hotline number Other

  • How employees report incidents
  • How supervisors report incidents
  • How to fill out an incident report form
  • How to access an anonymous “800”, toll free, or hotline number
  • Other

• Specify

• 15 Does your establishment’s workplace violence program or policy address incidents that occur<br>outside the workplace but have a workplace component or connection (e.g. harassment, stalking, physical harm, or verbal threats)?

  Yes

  No

• 16 Does your establishment periodically review the effectiveness or impact of the workplace violence program or policy?

  Yes

  No

• What is included in such a review? Check ALL that apply.

  Select Employee survey Number of violent incidents recorded Costs associated with incidents (e.g. worker’s compensation) Other

  • Employee survey
  • Number of violent incidents recorded
  • Costs associated with incidents (e.g. worker’s compensation)
  • Other

• Specify

• 17 Which office or persons are responsible for addressing the prevention of workplace violence in your establishment?

  Select No office or person has this responsibility Management/Supervisors Designated Employees Union Representatives Employee Assistance Program Human Resources Owner/CEO Security Occupational Safety and Health Risk Management Loss Prevention Other__________________________________ Don’t know

  • No office or person has this responsibility
  • Management/Supervisors
  • Designated Employees
  • Union Representatives
  • Employee Assistance Program
  • Human Resources
  • Owner/CEO
  • Security
  • Occupational Safety and Health
  • Risk Management
  • Loss Prevention
  • Other__________________________________
  • Don’t know

• Specify

• 18 If more than one office or person is responsible, who has the PRIMARY responsibility or would take the lead in addressing the prevention of workplace violence? Check only ONE.

  Select No single office or person. It’s a shared responsibility. Management/Supervisors Designated Employees Union Representatives Employee Assistance Program Human Resources Owner/CEO Security Occupational Safety and Health Risk Management Loss Prevention Other__

  • No single office or person. It’s a shared responsibility.
  • Management/Supervisors
  • Designated Employees
  • Union Representatives
  • Employee Assistance Program
  • Human Resources
  • Owner/CEO
  • Security
  • Occupational Safety and Health
  • Risk Management
  • Loss Prevention
  • Other__

• Specify

• 19 Does your establishment currently have a committee, team, or working group that addresses workplace violence prevention?

  Select No, but had a committee, team, or working group in the past No, never had a committee, team, or working group Yes

  • No, but had a committee, team, or working group in the past
  • No, never had a committee, team, or working group
  • Yes

• Who makes up the workplace violence committee, team, or working group? Check ALL that apply.

  Select Management/Supervisors Designated Employees Union Representatives Employee Assistance Program Human Resources Owner/CEO Security Occupational Safety and Health Risk Management Loss Prevention Other _

  • Management/Supervisors
  • Designated Employees
  • Union Representatives
  • Employee Assistance Program
  • Human Resources
  • Owner/CEO
  • Security
  • Occupational Safety and Health
  • Risk Management
  • Loss Prevention
  • Other _

• Specify

• 20 What are or were the functions of the workplace violence prevention committee, team, or working group? Check ALL that apply.

  Select … Develop an initial workplace violence program or policy … Raise workplace violence awareness … Conduct workplace violence training … Establish workplace violence prevention strategies … Evaluate the workplace for risk factors … Recommend additional security measures … Maintain security equipment … Respond to and/or investigate any workplace violence incidents … Review all workplace violence reports or incidents to identify patterns … Other

  • … Develop an initial workplace violence program or policy
  • … Raise workplace violence awareness
  • … Conduct workplace violence training
  • … Establish workplace violence prevention strategies
  • … Evaluate the workplace for risk factors
  • … Recommend additional security measures
  • … Maintain security equipment
  • … Respond to and/or investigate any workplace violence incidents
  • … Review all workplace violence reports or
  • incidents to identify patterns
  • … Other

• Specify

Section III: Training

• ► Answer questions for ALL employees including contractors and subcontractors who work for the reporting site.

• 21 Does your establishment provide material on workplace violence prevention to employees?

  Yes

  No

• What types of material are available? Check ALL that apply.

  Select Brochures on workplace violence prevention Posters on workplace violence prevention Newsletters, notices on the Intranet, or bulletins in newsletters on workplace violence prevention Memo or guidelines regarding how to report an incident related to workplace violence Memo or guidelines regarding security measures (e.g. card keys, ID badges) that specifically address workplace violence prevention Other _

  • Brochures on workplace violence prevention
  • Posters on workplace violence prevention
  • Newsletters, notices on the Intranet, or bulletins in newsletters on workplace violence prevention
  • Memo or guidelines regarding how to report an incident related to workplace violence
  • Memo or guidelines regarding security measures (e.g. card keys, ID badges) that specifically address workplace violence prevention
  • Other _

• Specify

• 22 Does your establishment provide training to employees on workplace violence prevention,<br>even if it is given during company trainings such as new employee orientation?

  Yes

  No

• Which of the following topics are addressed in your workplace violence prevention training? Check ALL that apply.

  Select Workplace violence program or policy How to address Domestic Violence by a family member, boyfriend, or girlfriend at the workplace Risk factors for workplace violence (e.g. working alone, working in high crime areas) Prevention strategies (e.g. limiting the amount of cash on-hand, escorts to parking areas) How employees should report concerns and incidents of workplace violence Other

  • Workplace violence program or policy
  • How to address Domestic Violence by a family member, boyfriend, or girlfriend at the workplace
  • Risk factors for workplace violence (e.g. working alone, working in high crime areas)
  • Prevention strategies (e.g. limiting the amount of cash on-hand, escorts to parking areas)
  • How employees should report concerns and incidents of workplace violence
  • Other

• Specify

• 23 During the past 12 months, how many hours of training specific to workplace violence prevention did EACH employee group receive?
  Check ONE box for each group.
  

• A. Newly hired employees

  Select No training 1 hour or less 1-2 hours 3-4 hours 5-8 hours 9 or more hours

  • No training
  • 1 hour or less
  • 1-2 hours
  • 3-4 hours
  • 5-8 hours
  • 9 or more hours

• B. Non-supervisory employees

  Select No training 1 hour or less 1-2 hours 3-4 hours 5-8 hours 9 or more hours

  • No training
  • 1 hour or less
  • 1-2 hours
  • 3-4 hours
  • 5-8 hours
  • 9 or more hours

• C. Supervisory / managerial employees

  Select No training 1 hour or less 1-2 hours 3-4 hours 5-8 hours 9 or more hours

  • No training
  • 1 hour or less
  • 1-2 hours
  • 3-4 hours
  • 5-8 hours
  • 9 or more hours

• D. Contractors / sub-contractors

  Select No training 1 hour or less 1-2 hours 3-4 hours 5-8 hours 9 or more hours No such staff

  • No training
  • 1 hour or less
  • 1-2 hours
  • 3-4 hours
  • 5-8 hours
  • 9 or more hours
  • No such staff

• E. High-risk employees Include employees that may be at greater risk of workplace violence than other employees (e.g. clerks in convenience stores, emergency department staff in hospitals, security guards, and receptionists).

  Select No training 1 hour or less 1-2 hours 3-4 hours 5-8 hours 9 or more hours No such staff

  • No training
  • 1 hour or less
  • 1-2 hours
  • 3-4 hours
  • 5-8 hours
  • 9 or more hours
  • No such staff

• 24 Which of the following training methods are used in your workplace violence training? Check ALL that apply.

  Select Classroom, instructor led (formal classroom) Self-paced (includes computer-based) On the job; one on one (informal) Written policies or manuals (references)

  • Classroom, instructor led (formal classroom)
  • Self-paced (includes computer-based)
  • On the job; one on one (informal)
  • Written policies or manuals (references)

• A. Newly hired employees

  Select No training Classroom, instructor led Selfpaced On-thejob;one-on one Written policies or manuals Other (list)*

  • No training
  • Classroom, instructor led
  • Selfpaced
  • On-thejob;one-on one
  • Written policies or manuals
  • Other (list)*

• Specify

• B. Non-supervisory employees

  Select No training Classroom, instructor led Selfpaced On-thejob;one-on one Written policies or manuals Other (list)*

  • No training
  • Classroom, instructor led
  • Selfpaced
  • On-thejob;one-on one
  • Written policies or manuals
  • Other (list)*

• Specify

• C. Supervisory / managerial employees

  Select No training Classroom, instructor led Selfpaced On-thejob;one-on one Written policies or manuals Other (list)*

  • No training
  • Classroom, instructor led
  • Selfpaced
  • On-thejob;one-on one
  • Written policies or manuals
  • Other (list)*

• Specify

• D. Contractors / sub-contractors

  Select No training Classroom, instructor led Selfpaced On-thejob;one-on one Written policies or manuals Other (list)*

  • No training
  • Classroom, instructor led
  • Selfpaced
  • On-thejob;one-on one
  • Written policies or manuals
  • Other (list)*

• Specify

• E. High-risk employees Include employees that may be at greater risk of workplace violence than other employees (e.g. clerks in convenience stores, emergency department staff in hospitals, security guards, and receptionists).

  Select No training Classroom, instructor led Selfpaced On-thejob;one-on one Written policies or manuals Other (list)*

  • No training
  • Classroom, instructor led
  • Selfpaced
  • On-thejob;one-on one
  • Written policies or manuals
  • Other (list)*

• Specify

• 25 How often are employees required to participate in workplace violence prevention training at your establishment?
  Check ONE box for each group.

• A. Non-supervisory employees

  Select Not required One or more times per year Every 1-2 years Every 3-5 years After an incident occurs Other (list)

  • Not required
  • One or more times per year
  • Every 1-2 years
  • Every 3-5 years
  • After an incident occurs
  • Other (list)

• Specify

• B. Supervisory / managerial employees

  Select Not required One or more times per year Every 1-2 years Every 3-5 years After an incident occurs Other (list)

  • Not required
  • One or more times per year
  • Every 1-2 years
  • Every 3-5 years
  • After an incident occurs
  • Other (list)

• Specify

• C. Contractors / sub-contractors

  Select No such staff Not required One or more times per year Every 1-2 years Every 3-5 years After an incident occurs Other (list)

  • No such staff
  • Not required
  • One or more times per year
  • Every 1-2 years
  • Every 3-5 years
  • After an incident occurs
  • Other (list)

• Specify

• D. High-risk employees Include employees that may be at greater risk of workplace violence than other employees (e.g. clerks in convenience stores, emergency department staff in hospitals, security guards, and receptionists).

  Select No such staff Not required One or more times per year Every 1-2 years Every 3-5 years After an incident occurs Other (list)

  • No such staff
  • Not required
  • One or more times per year
  • Every 1-2 years
  • Every 3-5 years
  • After an incident occurs
  • Other (list)

• 26 Does your establishment provide separate training on Domestic Violence prevention?

  Yes

  No

Section IV: Reporting

• ► Answer questions for ALL employees including contractors and subcontractors who
  work for the reporting site.

• 27 During the past 12 months, have employees at your establishment experienced any incidents of workplace violence, even those that did not result in injury?

  No

  Yes

• Which of the following types of workplace violence incidents occurred? Check ALL that apply. Criminal: when the perpetrator has no legitimate relationship to the business or its employees and is usually committing a crime in conjunction with the violence (e.g. robbery, shoplifting, or trespassing). Customer or Client: when the perpetrator has a legitimate relationship with the business and becomes violent while being served by the business (e.g. customers, clients, patients, students, inmates, or for any other group that the business provides services). Co-Worker: when the perpetrator is an employee, past employee of the business, or contractor who works as a temporary employee on your site and who attacks or threatens another employee. Domestic Violence: when the perpetrator, who has no legitimate relationship to the business (but has a personal relationship with the intended victim), threatens or assaults the employee at the workplace (e.g. family member, boyfriend, or girlfriend).

  Select Criminal Customer or Client: Co-Worker Domestic Violence:

  • Criminal
  • Customer or Client:
  • Co-Worker
  • Domestic Violence:

• 28 When did the most recent incident of workplace violence occur? Check only ONE.

  Within the last 30 days

  1 to 3 months ago

  4 to 6 months ago

  7 to 12 months ago

  12 months or longer

• 29 Did your establishment’s workplace violence prevention program or policy change after an<br>incident occurred? Check only ONE.

  No

  Yes

  No program or policy

• 30 During the past 12 months, have incidents of workplace violence……. Check only ONE

  Increased

  Decreased

  Stayed about the same

• 31 In your opinion, during the past 12 months, has an incident of workplace violence affected<br>employees at your establishment?

  No

  Yes

• In which of the following ways? Check ALL that apply.

  Select Absenteeism Health insurance premiums Turnover Fear levels Productivity Morale Other_____________________ Don’t know

  • Absenteeism
  • Health insurance premiums
  • Turnover
  • Fear levels
  • Productivity
  • Morale
  • Other_____________________
  • Don’t know

• Specify

• 32 Do you think that your establishment is……. Check only ONE.

  Select Very safe from workplace violence Safe from workplace violence Unsafe from workplace violence Very unsafe from workplace violence Don’t know

  • Very safe from workplace violence
  • Safe from workplace violence
  • Unsafe from workplace violence
  • Very unsafe from workplace violence
  • Don’t know

• 33 Do you think that your establishment is…….<br>Check only ONE.

  Very safe from crime

  Safe from crime

  Unsafe from crime

  Very unsafe from crime

  Don’t know

• 34 Do you think that the neighborhood around your establishment is……. Check only ONE. <br>

  Very safe from crime

  Safe from crime

  Unsafe from crime

  Very unsafe from crime

  Don’t know

• 35 Does your establishment track the cost of workplace injuries and illnesses?

  Yes

  No

• 36 Does your establishment track costs related to incidents of workplace violence?

  No

  Yes

• What types of costs related to workplace violence do you track? Check ALL that apply.

  Select Workers' compensation Third party insurance Absenteeism, accident or injury-related leave Replacement workers Property damage Training or prevention costs Other

  • Workers' compensation
  • Third party insurance
  • Absenteeism, accident or injury-related leave
  • Replacement workers
  • Property damage
  • Training or prevention costs
  • Other

• Specify

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