PERSONAL AND WORKPLACE
SAFETY SURVEY
FILL FORM
Personal and Workplace Information
What is your job title?
How large is your workplace? (# of employees)
Who is your employer?
How many years have you been working at your current job?
What is your site location?
*
Spring Valley Centre
Hilton
Discovery Harbour
Sunridge Place
Normanna
Dania
Finnish Manor
Cartier House
Eden Care Centre
Andover Terrace
West Shore Laylum
Lynn Valley Care Centre
Employment Status
Option 1
Part time
Facility Design and Field Work
6. Is access to office areas/employees’ workstations restricted to only authorized staff and escorted guests?
Yes
Option 2
Don't Know
7. Are all areas that employees walk through (e.g., parking lots, hallways, stairwells, etc.) secure and well lit?
Yes
No
Are employees who conduct field work provided with personal alarm systems, beepers, phones, or other means of directly communicating a need for assistance?
Yes
Don't Know
No
How can security be improved at your workplace or in the field (e.g., better lighting, more security personnel, metal detectors)?
Training
11. Have you received any training on how to deal with potentially violent situations?
Yes
No
Has your training prepared you to deal with violent situations that may arise in your working environment?
Yes
No
Don't Know
Employer Policies
Is there a violence prevention program at your workplace?
Yes
No
Don't Know
Does your workplace have a written policy concerning violence?
Yes
No
Don't Know
Have you read it?
Yes
No
Is there a program to provide support for employees who are victims of violence?
Yes
No
Don't Know
Violent Incidents
Have you ever been harassed at your current job?
Yes
No
Who harassed you?
Client
Inmate
Patient
Resident
Stranger
Relative of friend of patient/client/inmate
Co-worker (or former co-worker)
Manager/Supervisor
Spouse/Lover (or former spouse/lover)
Other
Other
Please describe
Have you ever been threatened at your current job?
Yes
No
Who threatened you?
Client
Inmate
Patient
Resident
Relative or friend of patient/client/inmate
Co-worker (or former co-worker)
Spouse/lover (or former spouse/lover)
Other
Other
Please describe the nature of the threat
Threat to injure or kill you.
Threat of personal property damage.
Threat to injure or kill your family.
Other
Other
Have you ever been physically assaulted at your current job?
Yes
No
Single Line Text
Section
Who physically assaulted you?
Client
Inmate
Patient
Resident
Relative or friend of patient/client/inmate
Co-worker (or former co-worker)
Other
Other
Grabbed?
Yes
No
How many occasions?
Most recent occurrence
Slapped?
Yes
No
How many occasions?
Most recent occurrence
Pushed?
Yes
No
How many occasions?
Most recent occurrence
Kicked?
Yes
No
How many occasions?
Most recent occurrence
Hit with a fist?
Yes
No
How many occasions?
Most recent occurrence
Hit with an object?
Yes
No
How many occasions?
Most recent occurrence
Knifed (or attempted)
Yes
No
How many occasions?
Most recent occurrence
Describe any additional information
Where did your most recent violent incident occur?
Office
Parking lot
Client's residence
While traveling to or from a client visit
Other
Other
Were you alone when you were assaulted?
Yes
No
What was the extent of your most recent injury?
Cuts
Bruises
Broken bones
Internal injury
Psychological trauma
Other
Other
Did you seek medical attention for your most recent injury?
Yes
No
Did you need to stay overnight in a hospital for your most recent injury?
Yes
No
Did you lose time from work as a result of your most recent injury(s)?
Yes
No
How many days?
Did you ever report an incident (harassment, threat, or physical assault) to management?
Yes
No
Describe how management responded and what actions were taken.
Personal Opinion
On a scale of 1 to 10 (1 = not worried, 10 = very worried), how concerned are you about your personal safety at work?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 (1 = not prepared, 10 = very prepared), how prepared do you feel to handle a violent situation (i.e., physical injury, threat, or harassment)?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 (1 = not committed, 10 = very committed), how would you rate your employer’s commitment to preventing workplace violence?
1
2
3
4
5
6
7
8
9
10
Have you seriously considered changing your occupation due to violent incidents you were involved in, witness to, or knew about?
Yes
No
Additional Comments:
