Periodically surveying employees on workplace
violence can be a valuable tool for evaluating your workplace violence prevention efforts
and gathering suggestions for improving your program. Some employees may prefer not to
have their names identified on a survey; making the name "optional" may increase
the amount of feedback you receive.
Work Location (if at alternate worksite) _________________________________________
Please assess your department/unit over the last year. Circle TRUE (T), FALSE (F) or
DON’T KNOW (?). Thank you for your honest assessment.
| Management
Commitment and Employee Involvement |
| T |
F |
? |
- Violence/threats are not accepted as "part of the job" by managers,
supervisors and/or employees.
|
| T |
F |
? |
- Employees communicate information about potentially assaultive/threatening clients or
visitors to appropriate staff.
|
| T |
F |
? |
- Management communicates information to employees about incidents of workplace violence.
|
| T |
F |
? |
- Employees feel they are treated with dignity and respect by other employees and
management.
|
| T |
F |
? |
- Employees are basically satisfied with their jobs.
|
| T |
F |
? |
- Employees are basically satisfied with management.
|
| T |
F |
? |
- Employees are basically satisfied with the organization (i.e., mission, vision, goals).
|
| T |
F |
? |
- Employees generally feel "safe" when they are at work.
|
| T |
F |
? |
- Employees are familiar with the department’s/unit’s violence prevention
policy.
|
| Potential
Risk Factors |
| T |
F |
? |
- Employees do not work in high-crime areas.
|
| T |
F |
? |
- Employees do not work with drugs.
|
| T |
F |
? |
- Employees do not work with cash.
|
| T |
F |
? |
- Employees do not work with patients or clients who have a history of violent behavior or
behavior disorders.
|
| T |
F |
? |
- Employees do not work in isolated work areas.
|
| Hazard
Prevention and Control |
| T |
F |
? |
- The department/unit has adequate lighting to, from and within the worksite.
|
| T |
F |
? |
- The employee parking garage is secure when arriving, leaving and during changes of
shift.
|
| T |
F |
? |
- Access and freedom of movement within the workplace are restricted to those persons who
have a legitimate reason for being there.
|
| T |
F |
? |
- Alarm systems such as panic alarm buttons, silent alarms, or personal electronic alarm
systems are being used for prompt security assistance.
|
| T |
F |
? |
- Employees know to use security escort service after hours.
|
| T |
F |
? |
- After hours, the building is locked down with only one access point.
|
| T |
F |
? |
- Visitors are signed in and out.
|
| Hazard
Prevention and Control (continued) |
| T |
F |
? |
- Exits are accessible and clearly marked.
|
| T |
F |
? |
- Employees are able to locate emergency equipment such as fire alarm boxes or
emergency generator outlets.
|
| T |
F |
? |
- Emergency equipment is accessible and free from obstruction.
|
| T |
F |
? |
- Employees are able to locate cellular phones, power-failure phones and/or radios for
emergency communication.
|
| T |
F |
? |
- Employees know proper procedures if a bomb threat is announced.
|
| T |
F |
? |
- Employee emergency call-back list is up-to-date and available.
|
| T |
F |
? |
- Employees provide privacy to reflect sensitivity and respect for clients and visitors.
|
| T |
F |
? |
- Employees use the "buddy system" to work together if problems arise.
|
| T |
F |
? |
- Employees working in the field have cellular phones or other communication devices to
enable them to request aid.
|
| T |
F |
? |
- Staffing levels are appropriate for department/unit functions.
|
| T |
F |
? |
- Reference manuals are up-to-date and available to employees.
|
| T |
F |
? |
- There is a grievance policy available to employees.
|
| T |
F |
? |
- There is a Safety Committee available as a resource to staff for any hazard concern.
|
| Training |
| |
|
|
- Employees have received training on the company’s workplace violence prevention
program.
|
| T |
F |
? |
- Employees know how to ask for assistance by phone or by alerting other staff.
|
| T |
F |
? |
- Employees have been trained to recognize and handle threatening, aggressive, or violent
behavior.
|
| T |
F |
? |
- Employees have been trained in verbal de-escalation techniques.
|
| T |
F |
? |
- Employees have been trained in self-defense/restraint procedures.
|
| Incidents
and Reporting |
| T |
F |
? |
- This work unit/department has not experienced violent behavior and assaults or threats
from strangers.
|
| T |
F |
? |
- This work unit/department has not experienced violent behavior and assaults or threats
from clients or customers.
|
| T |
F |
? |
- This work unit/department has not experienced violent behavior and assaults or threats
from others employed in the organization.
|
| T |
F |
? |
- This work unit/department has not experienced domestic violence issues.
|
| T |
F |
? |
- Employees are required to report incidents or threats of violence, regardless of injury or severity; the reporting system is clear.
|
| T |
F |
? |
- Medical and psychological counseling services were offered to employees who have been
assaulted or threatened.
|
