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Model Workplace Violence Hazard Assessment Form

The starting point in preventing workplace violence is to perform a hazard assessment and determine if violence is a real or potential hazard at your work site. Here’s a form you can use as a checklist and means of organizing a workplace violence hazard assessment at your own site.

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WORKPLACE VIOLENCE HAZARD ASSESSMENT FORM

Instructions: Completion of this Form by a competent person is an integral element of the workplace violence hazard assessment process.Name of Competent Person: ___________________________      Position: ________________________
Date: __________________      Signature: ___________________________________________________

 

PRIOR INCIDENTS OF WORKPLACE VIOLENCE

Have there been any incidents of violence at the workplace in the past 3 years?  [YES]  [NO]

If YES, indicate:

Number of incidents: ___________________________________________________________________

Frequency of incidents: _________________________________________________________________

For each incident, indicate:

Time & date of incident: _________________________________________________________________

Location of incident: ____________________________________________________________________

Job classification of workers involved in incident: _____________________________________________

Severity of incident: ____________________________________________________________________

Description of incident (attach separate sheet if necessary): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Corrective actions implemented, if any, as a result of incident: (attach separate sheet if necessary): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PRIOR INCIDENTS AT SIMILAR OPERATIONS

Have there been any incidents of violence at the workplaces of other companies in our industry in the past 3 years?  [YES]  [NO]

If YES, indicate:

Number of incidents: ___________________________________________________________________

Frequency of incidents: _________________________________________________________________

Location of incident: ____________________________________________________________________

Job classification of workers involved in incident: _____________________________________________

Severity of incident: ____________________________________________________________________

Other relevant information about incident: _________________________________________________

 

WORK-RELATED RISK FACTORS

Check off the following activities in which workers engage:

[  ] Handling cash

[  ] Protecting or securing valuables

[  ] Transporting people and goods

[  ] Working in a mobile workplace (e.g., a vehicle)

[  ] Delivering, collecting, selling, serving or storing drugs or liquor

[  ] Public or community contact

[  ] Working with unstable or volatile people

[  ] Working alone or in isolation

[  ] Working late nights or very early mornings

[  ] Other (please indicate)

 

PHYSICAL ENVIRONMENT
Parking Lot
Risk Factor YES NO Comment
Are entrances well marked?
Are entrances well lit?
Are exits well marked?
Are exits well lit?
Is the lot patrolled?*If yes, are there signs indicating this?
Is the lot monitored by surveillance cameras?*If yes, are there signs indicating this?
Have vehicles been stolen or vandalized?
Is the lot isolated?
Is there an emergency phone or other method in the lot for summoning help?
Are there hiding areas?
Outside & Around the Workplace
Risk Factor YES NO Comment
Are all areas well marked?
Are all areas well lit?
Are entrances and exits well marked?
Are entrances and exits well lit?
Are the building and outside areas patrolled?*If yes, are there signs indicating this?
Are the building and outside areas monitored by surveillance cameras?*If yes, are there signs indicating this?
Have there been incidents of violence or vandalism in any areas? (indicate which)
Is the building isolated?
Are there gates or fences around the building to limit access?
Is access to the building restricted?
Is the building kept locked? If yes:*When?

*Are keys or cards immediately replaced when lost or stolen?
Is there a system to alert staff members when somebody enters?
Reception Areas
Risk Factor YES NO Comment
Is access restricted? If so, how?
Is access from the reception area to other building areas restricted? If so, how?
Are all areas well lit?
Is there a clear view of all entrances and exits?
Are entrances and exits well lit?
Are there hiding places?
Is furniture designed and arranged so as to minimize contact between staff members and the public?
Is furniture secured to the floor?
Is there a way to call for help?
Is there a clear, unobstructed means of escape?
Are there any objects that could be used as weapons?
Is there a means of clearly identifying customers, clients or visitors (e.g., name tags or badges)?
General
Risk Factor YES NO Comment
Is there ample lighting?
Can the end of each stairwell, hall and elevator be seen?
Are there any other potential hiding places?
Are all areas well lit?
Is public access to washrooms controlled?
Are substantial amounts of cash and valuables kept on the site?
Is furniture designed and arranged so as to minimize contact between staff members and the public?
Is there a way to call for help?
Is there a clear, unobstructed means of escape?
Are there any objects that could be used as weapons?
Is there a means of clearly identifying customers, clients or visitors (e.g., name tags or badges)?
Are the premises patrolled or monitored? If so:*How?

*Are there signs indicating this?
POLICIES, PROCEDURES & TRAINING
Risk Factor YES NO Comment
Is a workplace violence prevention policy in place?*If so, is it posted?
Are there emergency response plans for violent incidents in place?
Have all staff members been trained in the emergency response procedures?
Are emergency response policies practiced and regularly reviewed?