720 Preventing Workplace Violence

Sample Employee Survey on Hazard Assessment

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.

Name (Optional)  _________________________________________________________________
Department/Unit  _____________________________________   Date  ____________________
Work Location  ____________________________________________________________________

Please assess your department/unit over the last year. Circle True, False, or Unknown. Thank you for your honest assessment.

Management Commitment and Employee Involvement

True	False	Unknown	Violence/threats are not accepted as "part of the job" by managers, supervisors and/or employees.
True	False	Unknown	Employees communicate information about potentially assaultive/threatening clients or visitors to appropriate staff.
True	False	Unknown	Management communicates information to employees about incidents of workplace violence.
True	False	Unknown	Employees feel they are treated with dignity and respect by other employees and management.
True	False	Unknown	Employees are basically satisfied with their jobs.
True	False	Unknown	Employees are basically satisfied with management.
True	False	Unknown	Employees are basically satisfied with the organization (i.e., mission, vision, goals).
True	False	Unknown	Employees generally feel "safe" when they are at work.
True	False	Unknown	Employees are familiar with the department’s/unit’s violence prevention policy.

Potential Risk Factors

True	False	Unknown	Employees do not work in high-crime areas.
True	False	Unknown	Employees do not work with drugs.
True	False	Unknown	Employees do not work with cash.
True	False	Unknown	Employees do not work with patients or clients who have a history of violent behavior or behavior disorders.
True	False	Unknown	Employees do not work in isolated work areas.

Hazard Prevention and Control

True	False	Unknown	The department/unit has adequate lighting to, from and within the worksite.
True	False	Unknown	The employee parking garage is secure when arriving, leaving and during changes of shift.
True	False	Unknown	Access and freedom of movement within the workplace are restricted to those persons who have a legitimate reason for being there.
True	False	Unknown	Alarm systems such as panic alarm buttons, silent alarms, or personal electronic alarm systems are being used for prompt security assistance.
True	False	Unknown	Employees know to use security escort service after hours.
True	False	Unknown	After hours, the building is locked down with only one access point.
True	False	Unknown	Visitors are signed in and out.
True	False	Unknown	Exits are accessible and clearly marked.
True	False	Unknown	Employees are able to locate emergency equipment such as fire alarm boxes or emergency generator outlets.
True	False	Unknown	Emergency equipment is accessible and free from obstruction.
True	False	Unknown	Employees are able to locate cellular phones, power-failure phones and/or radios for emergency communication.
True	False	Unknown	Employees know proper procedures if a bomb threat is announced.
True	False	Unknown	Employee emergency call-back list is up-to-date and available.
True	False	Unknown	Employees provide privacy to reflect sensitivity and respect for clients and visitors.
True	False	Unknown	Employees use the "buddy system" to work together if problems arise.
True	False	Unknown	Employees working in the field have cellular phones or other communication devices to enable them to request aid.
True	False	Unknown	Staffing levels are appropriate for department/unit functions.
True	False	Unknown	Reference manuals are up-to-date and available to employees.
True	False	Unknown	There is a grievance policy available to employees.
True	False	Unknown	There is a Safety Committee available as a resource to staff for any hazard concern.

Training

True	False	Unknown	Employees have received training on the company’s workplace violence prevention program.
True	False	Unknown	Employees know how to ask for assistance by phone or by alerting other staff.
True	False	Unknown	Employees have been trained to recognize and handle threatening, aggressive, or violent behavior.
True	False	Unknown	Employees have been trained in verbal de-escalation techniques.
True	False	Unknown	Employees have been trained in self-defense/restraint procedures.

Incidents and Reporting

True	False	Unknown	This work unit/department has not experienced violent behavior and assaults or threats from strangers.
True	False	Unknown	This work unit/department has not experienced violent behavior and assaults or threats from clients or customers.
True	False	Unknown	This work unit/department has not experienced violent behavior and assaults or threats from others employed in the organization.
True	False	Unknown	This work unit/department has not experienced domestic violence issues.
True	False	Unknown	Employees are required to report incidents or threats of violence, regardless of injury or severity; the reporting system is clear.
True	False	Unknown	Medical and psychological counseling services were offered to employees who have been assaulted or threatened.

Adapted from: Workplace Violence: Awareness and Prevention for Employers and Employees, Washington State Department of Labor and Industries