|
PART III
- Sample Workplace Violence Prevention Program (WPVP)
- Completed Written WPVP Program (Example)
- Sample Self Inspection Security Checklist
- Sample Incident Report Form
- Sample Employee Security Survey
SAMPLE
WORKPLACE VIOLENCE PREVENTION PROGRAM
POLICY STATEMENT
(Effective Date for Program)
Our establishment, [Employer Name] 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:_________________________ 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, OSHA 200 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:
____ OSHA 200 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.
RECORDKEEPING
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 OSHA 200 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
Name: Jane Doe
Name: Frank Kras
Name: James Brown
Name: Susan Dean
Name: Tom Jones
Name: Sally Field
|
Title: Vice President
Title: Operations
Title: Shop Steward
Title: Security
Title: Treasurer
Title: Legal Counsel
Title: Personnel
|
Phone: 555-1212
Phone: 555-1234
Phone: 555-1233
Phone: 555-1456
Phone: 555-1567
Phone: 555-1678
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, OSHA 200
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
Representative: Frank Kras
Representative: Jane Doe
|
Area General Office
Area Shop and Lab
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__ OSHA 200 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 11, 1995. 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.
RECORDKEEPING
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 OSHA 200 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: ______________________________________________________
____Yes ____No Security Control Plan:
If yes, does it contain:
-
____Yes ____No
____Yes ____No
____Yes ____No
Policy Statement
- Review of Employee Incident Exposure
- Methods of Control
If yes, does it include:
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
Evaluation of Incidents- Floor Plan
- Protection of Assets
- Computer Security
- Plan Accessible to All Employees
- Plan Reviewed and Updated Annually
- Plan Reviewed and Updated When Tasks Added or Changed
____Yes ____No Policy Statement by Employer
-
____Yes ____No Work Areas Evaluated by Employer
If yes, how often? ________________
-
____Yes ____No Engineering Controls
If yes, does it include:
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
Mirrors to see around corners and in blind spots - Landscaping to provide unobstructed view of the workplace
- "Fishbowl effect" to allow unobstructed view of the interior
- Limiting the posting of sale signs on windows
- Adequate lighting in and around the workplace
- Parking lot well lighted
- Door Control(s)
- Panic Button(s)
- Door Detector(s)
- Closed Circuit TV
- Stationary Metal Detector
- Sound Detection
- Intrusion Detection System
- Intrusion Panel
- Monitor(s)
- Video Tape Recorder
- Switcher
- Hand Held Metal Detector
- Hand held video camera
- Personnel traps ("Sally Traps")
- Other ______________________________
- Structural Modifications
____Yes ____No
Plexiglas, glass guard, wire glass, partitions, etc.
If yes, comment:____________________________________________
____________________________________________________________
- Security Guards
____Yes ____No
____Yes ____No
____Yes ____No
If yes, are there an appropriate number for the site?
- Are they knowledgeable of the company WPVP Policy?
- Indicate if they are:
______Contract Guards (1)
______In-house Employees (2)
____Yes ____No
____Yes ____No
____Yes ____No At Entrance(s) - Building Patrol
- Guards provided with communication?
If yes, indicate what type:_________________________________
____________________________________________________________
____Yes ____No
Guards receive training on Workplace Violence situations?
Comments:___________________________________________________
____________________________________________________________
____Yes ____No
Work Practice Controls
If yes, indicate:
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
Desks Clear of Objects which may become Missiles- Unobstructed Office Exits
- Vacant (Bare) Cubicles Available
- Reception Area Available
- Visitor/Client Sign In/Out
- Visitor(s)/Client(s) Escorted
- One Entrance Used
- Separate Interview Area(s)
- I.D. Badges Used
- Emergency Numbers Posted By Phones
- Internal Phone System
If yes, indicate:
____Yes ____No
____Yes ____No
Does it Use 120 VAC Building Lines
Does it Use Phone Lines
-
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
Internal Procedures for Conflict(Problem) Situations
- Procedures for employee dismissal
- Limit Spouse & Family Visits to Designated Areas
- Key Control Procedures
- Access Control to the Workplace
- Objects which may become Missiles Removed from Area
- Parking Prohibited in Fire Zones
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.)
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
____Yes ____No
Trained in hazardous situation avoidance- Briefed about areas where they work
- Have reviewed past incidents by type and area
- Know directions and routes for day's schedule
- Previewed client/case histories
- Left an itinerary with contact information
- Have periodic check-in procedures
- After hours contact procedures
- Partnering arrangements if deemed necessary
- Know how to control/defuse potentially violent situations
- Supplied with personal alarm/cellular phone/radio
- Limit visible clues of carrying money/valuables
- Carry forms to record incidents by area
- Know procedures if involved in incident
(see also Training Section)
-
____Yes ____No Training Conducted
If yes, is it:
____Yes ____No
____Yes ____No
____Yes ____No
Prior to Initial Assignment- At Least Annually Thereafter
- Does it Include:
____Yes ____No Written Training Records Kept____Yes ____No Are Incidents Reported
If yes, are they:
____Yes ____No
____Yes ____No
Reported in Written Form- First Report of Injury Form (If Employee Loses Time)
____Yes ____No Incidents Evaluated
____Yes ____No EAP Counseling Offered- Other Action (Reporting Requirements, suggestions, reporting to local authorities, etc.)
_______________________________________________________________
____Yes ____No Are Steps Taken to Prevent Recurrence? ____Yes ____No Floor Plans Posted Showing Exits, Entrances, Location of Security Equipment, Etc.
If yes, does it:
-
____Yes ____No Include an Emergency Action Plan, Evacuation Plan, and/or a Disaster Contingency Plan?
____Yes ____No Do Employees Feel Safe
____Yes ____No Have employees been surveyed to find out their concerns____Yes ____No Has the employer utilized the crime prevention services and/or lectures provided by the local or State police?
Comments:
_________________________________________________________________
General Comments/Recommendations:__________________________________________________
SAMPLE
INCIDENT REPORT FORM
- VICTIMS NAME:________________________ JOB TITLE:_______________
- VICTIMS ADDRESS:_______________________________________________
- HOME PHONE NUMBER:___________ WORK PHONE NUMBER:_______________
- EMPLOYERS NAME AND ADDRESS:____________________________________
- DEPARTMENT/SECTION:____________________________________________
- VICTIMS SOCIAL SECURITY NUMBER:________________________________
- INCIDENT DATE__________________________________________________
- INCIDENT TIME:_________________________________________________
- INCIDENT LOCATION:_____________________________________________
- WORK LOCATION (if different):_________________________________
- TYPE OF INCIDENT: (circle one): Assault, Robbery, Harassment, Disorderly Conduct, Sex Offense, Other. (Please Specify)
_________________________________________________________________
(See attached - DEFINITION OF INCIDENTS WORKSHEET)
- WERE YOU INJURED: (circle):
Yes No
If yes, please specify your injuries and the location of any
treatment:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
- DID POLICE RESPOND TO INCIDENT:
Yes No
- WHAT POLICE DEPARTMENT:______________________________________
- POLICE REPORT FILED:
Yes No
REPORT NUMBER: __________
- WAS YOUR SUPERVISOR NOTIFIED:
Yes No
- SUPERVISORS NAME:____________________________________________
- WAS THE LOCAL UNION/EMPLOYEE REPRESENTATIVE NOTIFIED:
Yes No
Who should be notified_____________________________________
- WAS ANY ACTION TAKEN BY EMPLOYER: (specify)
_________________________________________________________________
- ASSAILANT/PERPETRATOR: (circle one): Intruder, Customer, Patient, Resident, Client, Visitor, Student, Co-Worker, Former, Employee, Supervisor, Family/Friend, Other, (specify):
_________________________________________________________________
- ASSAILANT/PERPETRATOR - NAME/ADDRESS/AGE (if known):_________
_________________________________________________________________
_________________________________________________________________
- PLEASE BRIEFLY DESCRIBE THE INCIDENT:________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
- INCIDENT DISPOSITION: (Circle all that apply): No action taken,
Arrest, Warning, Suspension, Reprimand, Other:___________________
_________________________________________________________________
- DID THE INCIDENT INVOLVE A WEAPON: Yes/no Specify____________
_________________________________________________________________
- DID YOU LOSE ANY WORK DAYS:
Yes No
Specify __________________________________________________________
- WERE YOU SINGLED OUT OR WAS THE VIOLENCE DIRECTED AT MORE THAN
ONE INDIVIDUAL: _________________________________________________
- WERE YOU ALONE WHEN THE INCIDENT OCCURRED:___________________
- DID YOU HAVE ANY REASON TO BELIEVE THAT AN INCIDENT MIGHT
OCCUR:
Yes No
Why:_____________________________________________________________
- HAS THIS TYPE OR SIMILAR INCIDENT(S) HAPPENED TO YOU OR YOUR
CO-WORKERS:
Yes No
Specify:_________________________________________________________
- HAVE YOU HAD ANY COUNSELING OR SUPPORT SINCE THE INCIDENT:
Yes No
Specify:_________________________________________________________
- WHAT DO YOU FEEL CAN BE DONE IN THE FUTURE TO AVOID SUCH AN
INCIDENT:
________________________________________________________
- WAS THIS ASSAILANT INVOLVED IN PREVIOUS INCIDENTS:
_________________________________________________________________
- ARE THERE ANY MEASURES IN PLACE TO PREVENT SIMILAR INCIDENTS:
Yes No
Specify:_________________________________________________________
- HAS CORRECTIVE ACTION BEEN TAKEN:
Specify:_________________________________________________________
- 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)
- 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)
- 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?
- Are violence related incidents worse during shift work, on the road or
in other situations.
Please specify: __________________________
- 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)____________________________
- Have you ever noticed a situation that could lead to a violent
incident?
- Have you missed work because of a potential violent act(s) committed
during your course of employment?
- Do you receive workplace violence related training or assistance of
any kind?
- Has anything happened recently at your worksite that could have lead
to violence?
- Can you comment about the situation?
- Has the number of violent clients increased?
DEFINITION OF INCIDENTS
- 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.
- CRIMINAL MISCHIEF:
Intentional or reckless damaging of the property of another
person without permission.
- 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.
- 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.
- LARCENY:
Wrongful taking, depriving or withholding property from another
(no force involved). Victim may or may not be present.
- MENACING:
Intentionally places or attempts to place another person in fear
of imminent serious physical injury.
- RECKLESS ENDANGERMENT:
Subjecting individuals to danger by recklessly engaging in conduct
which creates substantial risk of serious physical injury.
- ROBBERY:
Forcible stealing of another's property by use of threat of
immediate physical force. (Victim is present and aware of theft).
- 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.
|
Back to Top
Previous part: PART II