The Workplace Violence Incident Survey is designed to collect information about physical, verbal, psychological, and sexual violence that has occrued in the workplace. The individual completing the survey is asked to record their experiences  as accurately as possible. The respondent can record an incident that was experienced personally or an incident witnessed in the workplace.

All information is anonymous and will be collated through Survey Monkey.

Thank you for your assistance in capturing information about workplace violence.

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* 1. What is your age range?

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* 2. Gender

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* 3. What is your employment status?

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* 4. What is your marital status?

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* 5. What is the highest degree or level of school you have completed?

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* 6. Have you ever been the victim or witness of workplace violence? If no go to question 19

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* 7. What type of workplace did the violence occur in? Note you can select area and also make comment. 

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* 8. Where in the workplace did the incident occur?

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* 9. Did any of the following factors contribute to the violence?

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* 10. When experiencing the violent incident, how long did it take?

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* 11. Select the type of violence and the relationship to the victim or yourself.

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* 12. Please indicate the individuals involved in the workplace violence incident.

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* 13. Please indicate the amount of lost work as a result of the workplace violence incident.

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* 14. What time frame did the workplace violence incident occur?

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* 15. How may people witnessed the incident? Please also indicate the number present.

  Number of witnesses 
Supervisor/manager
Staff member
Contractor
Security staff
Customer

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* 16. What was/were the outcome(s) for you after experiencing the workplace violence incident?
(Check all that apply)

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* 17. Please provide details of your experience of workplace violence.

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* 18. What action was taken to manage the incident

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* 19. What skills would you like to develop to help manage incidents of workplace violence?

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* 20. What can the employer do to help prevent violence in the workplace?

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* 21. Organisation Name (optional)

Thank you  for taking the time to complete this survey

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