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Employee Violence Risk Assessment Questionnaire

This questionnaire template for assessing the risk of violence is specifically tailored to assess an employee. It not only assesses the employee’s actions and behavior, but also whether the company has so far established a framework to prevent workplace violence in their company. This includes, among other things, an appropriate company policy, contact persons for those affected, and assistance for perpetrators and those affected.

Using the digital questionnaire with Lumiform’s mobile app, you can:

  • Lumiform’s flexible form builder offers the ability to customize or update the existing template, as well as easily create workplace violence risk assessment templates from scratch.
  • Fill out all forms digitally via the app without the need for paper and pen and save them digitally for the future.
  • Collect all aggregated information securely in Lumiform cloud storage and access it at any time, as well as share with the entire team instantly.
  • Quickly identify risks of violence through simple analytics and take immediate preventative action.
  • After each assessment, immediately generate a report that can be shared with all responsible persons without delay.
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Employee Violence Risk Assessment Questionnaire
General Information
Employee’s Nam
Job position
Historical and Demographic Items
Previously threatened, attempted or consummated violence towards others
Past use or threatened use of weapons outside work
Previous damage or destruction of work-related property
Substance abuse or dependence (alcohol and/or drugs)
Poor compliance with City attempts on counseling worker
Belligerence towards employees, customers or clients
Reckless or hazardous behavior on the job
Previous direct or veiled threats to harm other employees
Recent Events
Stress or desperation in workplace, domestic, or financial matters
Acquires firearms or related lethal equipment or weapons
Acquires firearms or related lethal equipment or weapons
Exposure to or increased use of de-Stabilizers (e.g., alcohol, drugs)
Fascination with or statements about other incidents of workplace violence
Poor compliance with recent directives of management
Lost job or perceives that job will soon be lost
Stalking, including repeated harassment, of other employees
Threats of suicide or homicide
Ongoing fantasies of hurting co-workers
Wishes to harm co-workers or management
Work Attitudes and Traits
Sees self as victimized by management or treated unfairly
Sense of identity wrapped up in job
Does not take criticism well; hypersensitive to perceived slights
Authority issues regarding control from others present
Tends to be a loner on and/or off job
Hostile attitudes or behaviors towards aspects of work
Erratic and/or irresponsible work traits
Attitudes that condone or support workplace violence
Minimizes or denies post maladaptive work behaviors
Creates, fosters, or allows a work atmosphere of fear and intimidation
Tends to have poor assertiveness skills
Organizational Deficiencies
Failure to screen work applicants for violence potential and mental problems
Failure to implement physical security measures to protect employees and clients/customers
Failure to implement a prevention-of-violence plan for relevant employees
Failure to act immediately to direct, implied or veiled threats of violence
Failure to create a crisis plan for ongoing violence
Failure to have an EAP, stress control, and anger management programs
Failure to have an out-referral program to community providers
Failure to train employees in the warning signs of violence
Failure to have clear polices for harassment, prejudice, grievance resolution, and discriminatory behavior
Failure to train employees to negotiate and communicate effectively with peers and management
Organization has a history of violence on worksite
Organization allows employee conflicts to occur without immediate intervention and follow up
Organization uses inconsistent disciplinary actions
Management is perceived as unfair, disrespectful, or discourteous to staff
The worksite is physically uncomfortable
Organization is moderate or large in size (More than 40 employees)
Performance standards are not linked to employee expectations
Performance standards do not have built-in employee input
The organization does not have written and regularly reviewed procedures for all of the above
Preliminary Risk Assessment
After answering the questions, how do you assess the risk?
List suggestions for further assessment or intervention here
Specify date and staff members to re-evaluate risk status
Additional relevant comments
Inspector's Signature
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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