ࡱ>  o0bjbj7H7H U"cU"c'@@4h!4UtI 3 ? IIKIKIKIKIKIKI$L^OoIG   G G oI4I*!!!G FII!G II!! ExHz FF$5IIHIF@P $PHHPHPG G !G G G G G oIoI!G G G IG G G G PG G G G G G G G G @ K: Workplace Violence Sample Policy Table of Contents Purpose Definitions Responsibilities Training Reporting Procedures Appendix A Types of Workplace Violence Appendix B - Workplace Violence Report Form I. Purpose The City of Sample will take all reasonable steps to provide a safe and secure work environment for all employees. The City has a zero tolerance for incidents of workplace violence and will not tolerate acts of Workplace Violence as defined below. Harassment, intimidation, assaults, stalking, or other violence, including threats of violence, direct or implied, by or against its employees, is prohibited. Violation of this policy may lead to disciplinary action up to and including termination from employment. Violations of this policy may also be reported to law enforcement authorities, as appropriate, or may subject violators to other legal action. Definitions Workplace Violence is defined as those incidents of violence that occur outside of normal job expectations or are not generally expected as part of regular staff duties. Incidents of violence may include but are not limited to physical or verbal threats in person, by letter or note, telephone, facsimile, or electronic mail; intimidation, harassment to include sexual harassment, and destruction of city property. All threats are presumed to constitute a statement of intent to harm. For purposes of this policy, a verbal threat is defined as any language communication. Serious incidents of workplace violence include but are not limited to physical assault, rape, murder, bomb threats, or incidents involving the use of a weapon. Generally, workplace violence is categorized into four types: violence by strangers, violence by customers/clients, violence by co-workers, and violence by personal relations. (See Appendix A). Incidents of workplace violence may occur either at or away from the workplace. The determining factors in assessing whether an incident constitutes workplace violence are: the individuals involved, the relationship of the action to the workplace, and the location of the incident. Responsibilities All City employees are expected to adhere to this workplace violence policy statement and are expected to treat each other with courtesy and respect. All City employees have the responsibility to be familiar with our workplace violence policy and be proactive in the prevention of workplace violence. IV. Training The City of Sample will provide relevant training and education on the following: Incident reporting and documentation procedures Procedures for filing a police report Workplace Violence Awareness De-escalation strategies Training curriculums may be subject to change as necessary. Reporting Procedures City employees or supervisors who witness or experience an occurrence or suspected occurrence of workplace violence must report the incident to their immediate supervisor or other appropriate manager. The supervisor or manager will determine whether police involvement is necessary. Conversely, if the employee feels that they are in immediate physical danger, they may call the police. Police can be called from any city building by dialing 911. After notifying the appropriate authorities, employees shall immediately notify a supervisor. All incidents of workplace violence shall be forwarded to the Safety Coordinator and Human Resource Director. (See Appendix B) Employees will be guaranteed that any incidents will be promptly and confidentially investigated and acted upon. There will be no retaliation against an employee who makes a good faith report of potential violence, actual violence or possession of a weapon. If questions arise, contact the Safety Coordinator. Appendix A Types of Workplace Violence There are four types of workplace violence identified by the Occupational Safety and Health Administration in which workplace violence incidents are categorized. Violence by Strangers In this type of incident, a stranger commits the violence. This stranger has no legitimate personal or business relationship to the worker or workplace and enters the workplace, usually on the pretence of being a customer, to commit a robbery or other violent act. Also, workers may be victimized by strangers outside the traditional workplace, but while acting within the course and scope of their employment. Violence by Customers/Clients In these incidents, the violence is committed by someone who receives a service provided by a business, such as a current or former customer, client or patient, a passenger, a criminal suspect or a prisoner. The violence can be committed in the workplace or outside the traditional workplace with service providers, while performing a job-related function. Violence of this category is divided into two sub-types. The first type involves people who may be inherently violent such as prison inmates, mental health service recipients, or other client populations. The second type involves people who are not known to be inherently violent, but are situationally violent. Something in the situation induces an otherwise non-violent customer or client to become violent. Typically, provoking situations are those, which are frustrating to the client or customer, such as denial of needed or desired services or delays in receiving such services. Violence by Co-workers In co-worker incidents, the perpetrator has an employment relationship with the workplace. The perpetrator can be a current or former employee, a prospective employee, a current or former supervisor, manager, or contractor. Co-worker violence that occurs outside the workplace, which resulted or arose from the employment relationship, is also included in this category. This type can again be divided into two types; 1) Violence between supervisors and subordinates, 2) Violence between worker at the same level. Violence by Personal Relations In personal relationship incidents, the violence is committed by someone who has a personal relationship with the worker, such as a current or former spouse or partner, a relative or friend. Also, included in this category is the perpetrator who has a personal dispute with the worker and enters the workplace to harass, threaten, injure or kill. Such incidents are referred to as domestic violence in the workplace. CITY OF SAMPLE Workplace Violence Report1. DEPARTMENT 2. SHIFT3. PAYROLL #4. NAME (Last) (First) (M.I.)PART I : EMPLOYEE IDENTIFICATIONWHO5. JOB TITLE6. DATE OF BIRTH / /7. SEX 1-MALE  2-FEMALE8. WORK ADDRESS (Street)9. ZIP CODE10.HOME PHONE ( )11. WORK PHONE ( )12. SUPERVISOR 13. ADMINISTRATOR 14. WORK ASSIGNMENTROUTINENON-ROUTINE15. WITNESSES: Last First MI Phone # Job Title (If Applicable) WITNESS#1: ____________________________________________________________________(______)_________________________________________________________________ WITNESS#2: ____________________________________________________________________(______)_________________________________________________________________ WITNESS#3: ____________________________________________________________________(______)_________________________________________________________________PERPETRATOR INFORMATION16. NAME (Last) (First) (M.I)17. DATE OF BIRTH / /18. SEX MALE  FEMALE19. EMPLOYEE RELATION 1-CO-WORKER 2- SUPERVISOR3-CLIENT 4-PUBLIC/STRANGER 5- SPOUSE6- SIGNIFICANT OTHER 7- FAMILY MEMBER 8- FRIEND/ACQUAINTANCE9- OTHER (Specify) 20. ADDRESS 21. ZIP CODE22. PHONE ( )23. OCCUPATION24. CASE HISTORY INFORMATION (If Applicable)WHEN25. DATE OF INCIDENT / /20___26. TIME OF INCIDENT A.M. P.M.27. DATE INCIDENT REPORTED A.M. P.M.28. TIME INCIDENT REPORTED / /20___ 29. USUAL / NORMAL WORK HOURS A.M. P.M.30. ROTATING SHIFT 1- YES 2-NO31. OVERTIME 1-YES 2. NO32. SHIFT WORK 1-YES 2-NO33. DATE OF HIRE / /WHERE*NOTE* COMPLETE ONLY ONE SECTION:34. INSIDE35. ADDRESS / BUILDING NAME36. EXACT LOCATION AT ADDRESS (Floor, Area, etc.) 37. OUTSIDE38. LOCATION /INTERSECTIONPART II: DESCRIPTION OF INCIDENT (Use additional sheets if necessary)WHAT AND HOW39. INCIDENT TYPE 1 -ASSAULT  2- NEAR-MISS 3-THREAT 4-HARASSMENTSPECIFY: 5-OTHER40. Supervisor Notified 1-YES 2-NO41. Weapon Used YES NO 42. TYPE / DESCRIPTION OF WEAPON: 43. POLICE CONTACTED 1- YES 2- NO44. PROTECTIVE ORDER / COURT DATE 1- YES 2- NO / / 45. EVIDENCE OF THREAT/ASSAULT/HARASSMENT? 1-YES 2-NO SPECIFY46. DESCRIBE INCIDENT IN DETAIL: WHAT, HOW, WHY; THREAT (S) OR VIOLENT ACT (S) CONDUCTED BY THE ALLEGED PERPETRATOR PRIOR TO THIS INCIDENT? WHAT SPECIFIC LANGUAGE WAS USED IN THE ASSAULT OR THREAT? (Use additional paper if necessary). 47. WORK ASSIGNEMENT: PLEASE CHECK THE MOST APPROPIATE CATEGORYA. Routine/Normal C. Emergency Response/AssignmentB. Non-Routine/Special Assignment D. Other  48. EMPLOYEE SIGNATURE49. DATE / /20PART III: FUNDAMENTAL CAUSE AND CORRECTIVE ACTION TO BE COMPLETED BY SUPERVISOR OR HUMAN RESOURCE DIRECTOR50. DISCUSS POSSIBLE FUNDAMENTAL CAUSE (S) OF INCIDENT: 51. LIST OR DESCRIBE ALL RECOMMENDED CORRECTIVE ACTIONS:52. DATE RECOMMENDATIONS IMPLEMENTED / /20PART IV: SIGNATURE AND DATE53.HUMAN RESOURCE DIRECTOR SIGNATURE54. 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