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Employee Risk Assessment Questionaire
1.
(a)Have you experienced verbal abuse while an employee of this organization? YesNo
(b)Ifyes,didyouorttheincident(s)?YesLJNo
(c)Ifyes,didyoureporttheincidents(s)? Verbally?Inwriting?
(d)What was the relationship of the abuser toyou?
Co-workerClient/Customer
Member ofthepublicOther(pleasespecify)
(e)Wheredidtheabuseoccur?(e.g.HumanResources,parkinglot,lockerroom, etc.)
(f)When did the abuse occur? i.e. year, month, week orday
2.
(a)Have you experienced a threat of phystcal Violence while an employee ofthis organization?
YesDNoD
(b)Ifyes,didyourrttheincident(s)?
YesLJNoD
(c)If yes, did you report the incidents(s)? Verbally?Inwriting?
VAH001-ViolenceandHarassment45
Revised November 2006
(d)What was the relationship of the abuser toyou?
0Co-workerDClient/Customer
DMemberofthepublicDOther (pleasespecify)
(e)Wheredidtheabuseoccur?(e.g.HumanResources,parkinglot,lockerroom, etc.)
(f)Whendidtheabuseoccur?i.e.year,month,weekorday
3.
(a)Have you experienced a physical assault or attack while an employee of this
organization?
YesDNoD
(b)Ifyes,didyourt theincident(s)?
YesLJNoD
(c)Ifyes,didyoureporttheincidents(s)?
Verbally?0Inwriting?D
(d)What was the relationship of the abuser toyou?
DCo-workerDClient/Customer
DMemberofthepublicDOther(pleasespecify)
(e)Wheredidtheabuseoccur?(e.g.HumanResources,parkinglot,lockerroom, etc.)
VAH001-ViolenceandHarassment46
Revised November 2006
(f)When did the abuse occur? i.e.year, month, week or day
4.Dfdyoumisstimefromworkasaresultofthevlolenceorharassment?YesLJNo
If yes, please indicate the length of absence from work.
days/wks/months
5.Doyou:
(a)Work alone or with a small number ofco-workers?
YesDNoD
(b)Worklateatnfghtorearlyinthemornlng? YesDNoD
6.Are you concerned about your safety on the job? YesDNoD
What is your source of concern?
VAH001-ViolenceandHarassment47
Revised November 2006
This form is for example purposes only. Completing this form alone will not necessarily put you in compliance with the legislation. It is important and necessary that you customize this document to meet the unique circumstances of your worksite. Further, it is essential that this document is not only complete, but is used, communicated, and implemented in accordance with the legislation. The Crown, its agents, employees or contractors will not be liable to you for any damages, direct or indirect, arising out of your use of this form.