2 minutes
If you are an employee, you are eligible to fill out a Workplace violence restraining order form if you were subjected to violence at work or if you have a reasonable belief that you will become a victim of violence at work.
What is your name?
What is your current address?
What is your current phone number?
What is your date of birth?
Are you currently employed?
If yes, where do you work?
What is your job title?
What are your job duties?
Have you ever been the victim of workplace violence?
If yes, please describe the incident(s).
Have you ever been the perpetrator of workplace violence?
If yes, please describe the incident(s).
Do you have any history of violence outside of the workplace?
If yes, please describe the incident(s).