Workplace Violence Hazard Assessment Form
The starting point in preventing workplace violence is to perform a hazard assessment and determine if violence is a real or potential hazard at your work site. Here’s a form you can use as a checklist and means of organizing a workplace violence hazard assessment at your own site.
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WORKPLACE VIOLENCE HAZARD ASSESSMENT FORM
Instructions: Completion of this Form by a competent person is an integral element of the workplace violence hazard assessment process.
Name of Competent Person: ___________________________ Position: ________________________ |
PRIOR INCIDENTS OF WORKPLACE VIOLENCE |
Have there been any incidents of violence at the workplace in the past 3 years’ [YES] [NO]
If YES, indicate:
Number of incidents: ___________________________________________________________________
Frequency of incidents: _________________________________________________________________
For each incident, indicate:
Time & date of incident: _____________________________________________________________________
Location of incident: ________________________________________________________________________
Job classification of workers involved in incident: ____________________________________________
Severity of incident: _________________________________________________________________________
Description of incident (attach separate sheet if necessary): ___________________________________________________________________________________________
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Corrective actions implemented, if any, as a result of incident: (attach separate sheet if necessary): ___________________________________________________________________________________________
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PRIOR INCIDENTS AT SIMILAR OPERATIONS |
Have there been any incidents of violence at the workplaces of other companies in our industry in the past 3 years’ [YES] [NO]
If YES, indicate:
Number of incidents:___________________________________________________________________
Frequency of incidents:_________________________________________________________________
Location of incident:____________________________________________________________________
Job classification of workers involved in incident: _________________________________________
Severity of incident:_____________________________________________________________________
Other relevant information about incident: _________________________________________________
WORK-RELATED RISK FACTORS |
Check off the following activities in which workers engage:
[ ] Handling cash
[ ] Protecting or securing valuables
[ ] Transporting people and goods
[ ] Working in a mobile workplace (e.g., a vehicle)
[ ] Delivering, collecting, selling, serving or storing drugs or liquor
[ ] Public or community contact
[ ] Working with unstable or volatile people
[ ] Working alone or in isolation
[ ] Working late nights or very early mornings
[ ] Other (please indicate)
PHYSICAL ENVIRONMENT | |||
Parking Lot | |||
Risk Factor | YES | NO | Comment |
Are entrances well marked’ | |||
Are entrances well lit’ | |||
Are exits well marked’ | |||
Are exits well lit’ | |||
Is the lot patrolled’
*If yes, are there signs indicating this’ |
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Is the lot monitored by surveillance cameras’
*If yes, are there signs indicating this’ |
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Have vehicles been stolen or vandalized’ | |||
Is the lot isolated’ | |||
Is there an emergency phone or other method in the lot for summoning help’ | |||
Are there hiding areas’ | |||
Outside & Around the Workplace | |||
Risk Factor | YES | NO | Comment |
Are all areas well marked’ | |||
Are all areas well lit’ | |||
Are entrances and exits well marked’ | |||
Are entrances and exits well lit’ | |||
Are the building and outside areas patrolled’
*If yes, are there signs indicating this’ |
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Are the building and outside areas monitored by surveillance cameras’
*If yes, are there signs indicating this’ |
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Have there been incidents of violence or vandalism in any areas’ (indicate which) | |||
Is the building isolated’ | |||
Are there gates or fences around the building to limit access’ | |||
Is access to the building restricted’ | |||
Is the building kept locked’ If yes:
*When’ *Are keys or cards immediately replaced when lost or stolen’ |
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Is there a system to alert staff members when somebody enters’ | |||
Reception Areas | |||
Risk Factor | YES | NO | Comment |
Is access restricted’ If so, how’ | |||
Is access from the reception area to other building areas restricted’ If so, how’ | |||
Are all areas well lit’ | |||
Is there a clear view of all entrances and exits’ | |||
Are entrances and exits well lit’ | |||
Are there hiding places’ | |||
Is furniture designed and arranged so as to minimize contact between staff members and the public’ | |||
Is furniture secured to the floor’ | |||
Is there a way to call for help’ | |||
Is there a clear, unobstructed means of escape’ | |||
Are there any objects that could be used as weapons’ | |||
Is there a means of clearly identifying customers, clients or visitors (e.g., name tags or badges)’ | |||
General | |||
Risk Factor | YES | NO | Comment |
Is there ample lighting’ | |||
Can the end of each stairwell, hall and elevator be seen’ | |||
Are there any other potential hiding places’ | |||
Are all areas well lit’ | |||
Is public access to washrooms controlled’ | |||
Are substantial amounts of cash and valuables kept on the site’ | |||
Is furniture designed and arranged so as to minimize contact between staff members and the public’ | |||
Is there a way to call for help’ | |||
Is there a clear, unobstructed means of escape’ | |||
Are there any objects that could be used as weapons’ | |||
Is there a means of clearly identifying customers, clients or visitors (e.g., name tags or badges)’ | |||
Are the premises patrolled or monitored’ If so:
*How’ *Are there signs indicating this’ |
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POLICIES, PROCEDURES & TRAINING | |||
Risk Factor | YES | NO | Comment |
Is a workplace violence prevention policy in place’
*If so, is it posted’ |
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Are there emergency response plans for violent incidents in place’ | |||
Have all staff members been trained in the emergency response procedures’ | |||
Are emergency response policies practiced and regularly reviewed’ |