Please take a moment to fill out this workplace violence survey. Your cooperation is necessary to ensure that all workers are properly protected from the threat of workplace violence.

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* 1. Have you experienced or witnessed any of the following at any place where you perform any work related duties? (Check all that apply)

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* 2. If yes, how frequently do these incidents happen? (check one)

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* 3. When did the latest incident occur?

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* 4. Are assaults, threats, and harassment common in your work area?

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Assaults
Threats
Harassment

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* 5. What best describes the perpetrator(s)? (Check all that apply)

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* 6. Typically, are incidents reported to management? Check one

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