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.
What is your age range?

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* 1. What is your age range?

Gender

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* 2. Gender

What is your employment status?

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* 3. What is your employment status?

What is your marital status?

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* 4. What is your marital status?

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

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

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

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

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

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

Where in the workplace did the incident occur?

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

Did any of the following factors contribute to the violence?

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

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

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

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

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

Please indicate the individuals involved in the workplace violence incident.

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

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

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

What time frame did the workplace violence incident occur?

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

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

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

Please provide details of your experience of workplace violence.

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

What action was taken to manage the incident

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* 18. What action was taken to manage the incident

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

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

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

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

Organisation Name (optional)

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* 21. Organisation Name (optional)

Thank you  for taking the time to complete this survey

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