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Section I

General Information

Location Name:

Year founded:


General Contact Telephone Number:

Security Contact Telephone Number:

Senior Executive Responsible for the Facility:

Security Department Head or Personnel Assigned Security Responsibility:

Contract Security Leadership:

Workplace Violence / Crime Prevention Committee Chairperson:

Workplace Violence / Crime Prevention Committee Vice Chair:

Facility Type:

Facility Size:

All Units:

Full-Time Employees:

Part-Time Employees:

Field Workers / Home Health:


Temporary Employees:

Section 2

Workplace Violence Prevention Plan


Statement by Senior Leadership:

Current Workplace Violence Program:

Overview of Patient, Client and Setting-Related Risk Factors:

Any Organizational Risk Factors:

Workplace Violence Prevention Training:

Supervisor and Management Training Courses:

Training of Security Staff:

Evaluation of Training:


Records Analysis and Tracking:

Job Hazard Analysis:

Employee Surveys:

Hazard Prevention and Control:

Administrative and Work Practice Controls:

Investigation of Incidents:

Recordkeeping and Program Evaluation:

Policies and procedures for obtaining medical care, trauma informed care, counseling, workers’ compensation, or legal assistance:

Section 3

Workplace violence probability table

Do employees have contact with the public?

Do they exchange money with the public?

Do they work alone?

Do they work late at night or during early morning hours?

Is the workplace often understaffed?

Is the workplace located in an area with a high crime rate?

Do employees enter areas with a high crime rate?

Do they have a mobile workplace (patrol vehicle, work van, etc.)?

Do they deliver passengers, goods, or services?

Do employees perform jobs that might put them in conflict with others?

Do they ever perform duties that could upset people (deny service, insurance benefits, etc.)?

Do they deal with people known or suspected of having a history of violence?

Do any employees or supervisors have a history of assault, verbal abuse, harassment, or other threatening behavior?

Other risk factors – please describe: