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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

Date

Employee’s Nam

Job position

Department

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?

Confirmation

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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