Survey of Workplace Violence 

Prevention 

U.S. Department of Labor 

Bureau of Labor Statistics 

 

 

 

 Please correct your company address as needed

 OMB No. 1220-0177 

 Approval expires 08/31/2007

 BLS-2005 WPV

 

 

 

 

 

 

 

 

 

 

Note: The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies will use the information you provide for 

statistical purposes only. This information will be held in confidence, as provided by the Confidential Information Protection and 

Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws. Your responses will not be 

disclosed in identifiable form without your informed consent. 

We estimate it will take an average of 20 minutes to complete this survey, including time for reviewing instructions, searching

existing data sources, gathering and maintaining the data needed, and completing and reviewing this information. If you have any 

comments regarding these estimates or any other aspect of this survey, including suggestions for reducing this burden, please send 

them to the Bureau of Labor Statistics, Occupational Safety and Health Statistics, 2 Massachusetts Avenue, N.E., Washington, D.C. 

20212. You are not required to respond to the collection of information unless it displays a currently valid OMB control number. 
 

Dear Employer: 

The U.S. Department of Labor, Bureau of Labor Statistics, is working with the National Institute for 

Occupational Safety and Health (NIOSH) to survey employers about the prevention of workplace 

violence. The Survey of Workplace Violence Prevention includes questions about your establishment’s 

operations, programs, and policies regarding workplace violence. Other questions are included about 

your establishment’s training programs to prevent workplace violence. 

We realize that you and your colleagues are very busy. Therefore, we have made the survey relatively 

quick and easy to complete. Your participation in this survey is voluntary, but we rely on 

establishments like yours to help us with this important research. 

The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the 

information you provide for statistical purposes only and will hold the information in confidence to the 

full extent permitted by law. In accordance with the Confidential Information Protection and Statistical 

Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your 

responses will not be disclosed in identifiable form without your informed consent. You will NOT be 

visited by any regulatory agency as a result of your participation in this survey. 

The results of this survey can be found at www.bls.gov by clicking on the 'Safety and Health' link. A 

News Release detailing the major findings will be available in the summer of 2006. If you would like 

a copy of the final results sent to you via mail or e-mail, please check a box under “Contact 

Information” on page 1 of the survey. 

Your participation will result in a survey that produces valuable and important information. Thank you 

for helping us collect accurate information and for participating in the effort to make America’s 

workplaces safer and healthier. 

Bureau of Labor Statistics 

U.S. Department of Labor 

What do you need to do? 

• Please forward this survey to the person(s) who is (are) most informed about the 

prevention of workplace violence, including training policies, throughout your 

establishment. This person should be knowledgeable about your establishment’s operations 

and programs or policies; training; and procedures on workplace violence prevention; and 

incidences of workplace violence. This may include persons from Safety and Health, Risk 

Management, Security, Loss Prevention, and/or Human Resources.

• Complete this survey only for the establishment(s) noted on the cover under Reporting Site.

• Verify the information printed on the cover under Your Company Address and make corrections 

where necessary.

• On Page 1, fill in the Contact Information (name, title, and telephone number) of the person 

whom we should contact for information.

• Please return the entire package – everything that we sent you – in the enclosed envelope or by 

e-mail within 30 days of the date your establishment received it. 

If you need help in completing our survey form or if you have questions, please call 202-691-6170 

(not a toll-free number).
 

Options for Reporting Your Survey of Workplace 

Violence Prevention Data 

Bureau of Labor Statistics 

U.S. Department of Labor 

The Bureau of Labor Statistics is pleased to offer two methods of reporting your Survey of Workplace Violence Prevention 

data. 

1. You can complete your survey booklet by hand and return it to us by using the enclosed Business Reply Mail 

envelope. 

2. You can receive an electronic copy of the survey form by e-mail, enter your data, and then return it to us via email. 

Reporting Your Survey of Workplace 

Violence Prevention Data By E-Mail 

Before you can report your data via e-mail you must 

obtain an electronic copy of the survey form. 

Note: If you report your survey data by e-mail, you do 

not need to mail back your survey form to us. 

As a participant in a U.S. Bureau of Labor Statistics 

(BLS) statistical survey, you should be aware that use of 

electronic transmittal methods in reporting data involves 

certain inherent risks to the confidentiality of those data. 

Further, you should be aware that responsible electronic 

transmittal practices employed by the BLS cannot 

completely eliminate those risks. 

The BLS is committed to the responsible treatment of the 

data you report and will take appropriate steps within 

their ability to protect the confidentiality of those data. 

The survey form is a Microsoft Word ® template that is 

formatted to allow you to type your information into 

each of the data fields. The fields in the electronic 

survey form correspond exactly to the fields on the hard 

copy survey form you received in the mail. 

1. To obtain an electronic copy of the survey form, 

send an e-mail to: WPVSURVEY@idcf.bls.gov. 

By an automated response, you will receive an 

electronic copy of the survey form to complete. Do 

not reply to this message—it is from an unattended 

mailbox and any replies will not be responded to or 

forwarded. 

2. Save the form to your computer and open it using 

Microsoft Word ®. 

3. Begin by entering your establishment’s identifying 

information on the cover page of the survey form. 

You will need to refer to the label on the front cover 

of the survey form you received in the mail. You 

must provide us with your establishment ID number 

and your company name and address. 

An example label is shown below. 

4. Once you have filled in your identifying information 

on the cover page, you can navigate through the 

fields on the form by using the TAB key. 

5. When you have completed the survey form, save it 

on your computer. 

6. Attach your completed survey form to an e-mail and 

send to: WPVDATA@idcf.bls.gov. You will 

receive an automated response when your survey 

form has been received by the BLS. Do not reply to 

this message—it is from an unattended mailbox and 

any replies will not be responded to or forwarded. 

Company name 

and address

Establishment 

ID number
1 

----------------------- START HERE ----------------------------- 

BEFORE you start answering the survey, please 

complete the following tasks: 

⇒ Report information only about the Reporting Site

identified on the address label. 

⇒ Verify the information printed on the cover under 

Your Company Address and make corrections 

where necessary. 

⇒ Forward this to the person who is most informed 

about workplace violence prevention in your 

establishment. 

 1 CONTACT INFORMATION — PLEASE PRINT: 

Name of person completing the survey: 

__________________________________________ 

Job title: 

__________________________________________ 

Phone number: (_______) _______--__________ 

 Ext. _______________________ 

Fax number: (_______) _______--__________ 

Month and day completed: _______ _____, 2005 

 Month Day 

If you would like a copy of the survey results, please 

check one or both of the boxes below. 

F I would like a copy of the survey results sent to my email address listed below. 

E-mail address: 

___________________________________ 

F I would like a copy of the survey results sent to my 

mail address listed below. 

Mail address: 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

 2 How many employees are currently employed by 

your establishment? 

⇒ Include all paid employees (full-time, part-time, 

hourly, salaried, temporary, and seasonal). 

 

NUMBER OF CURRENT 

EMPLOYEES: 

Survey of Workplace Violence 

Prevention 

DEFINITION of Workplace Violence 

Please use the following definition of workplace 

violence to answer the questions in this survey. 

Workplace violence can occur at the 

workplace, on official travel, at field locations, and at 

client’s homes or workplaces. Violence that occurs 

in the workplace may be classified in the following 

ways: 

• Criminal: when the perpetrator has no legitimate 

relationship to the business or its employees and 

is usually committing a crime in conjunction with 

the violence (e.g. robbery, shoplifting, or 

trespassing). 

• Customer or Client: when the perpetrator has a 

legitimate relationship with the business and 

becomes violent while being served by the 

business (e.g. customers, clients, patients, 

students, inmates, or for any other group that the 

business provides services). 

• Co-Worker: when the perpetrator is an 

employee, past employee of the business, or 

contractor who works as a temporary employee 

on your site and who attacks or threatens 

another employee. 

• Domestic Violence: when the perpetrator, who 

has no legitimate relationship to the business 

(but has a personal relationship with the 

intended victim), threatens or assaults the 

employee at the workplace (e.g. family member, 

boyfriend, or girlfriend). 

Workplace Violence violent acts directed 

towards a person at work or on duty (i.e. physical 

assaults, threats of assault, harassment, 

intimidation, or bullying). 
2

► Answer questions for ALL employees 

including contractors and subcontractors 

who work for the reporting site. 

 3 Which of the following types of security features are 

provided at your establishment, even if used as 

needed? 

 3a Electronic Surveillance — Check ALL that 

apply

 No electronic surveillance 

 Intruder/Burglar alarm systems 

 Surveillance cameras 

 Motion detectors 

 Metal detectors 

 X-ray inspection of items brought into 

workplace (e.g. bags, briefcases, packages) 

 Electronic badge or ID scanners at 

 entrances and exits to building or work 

 areas 

 Employees’ personal alarms 

 Other_____________________________ 

 3b Security Staff — Check ALL that apply

 No security staff 

 Campus or site-specific police 

 Security guards, including contracted 

 Guard dogs 

 Other_____________________________ 

 3c Physical Security — Check ALL that apply 

 No physical security features 

 Limited access (e.g. secured entrances or 

doors that are kept locked during working 

hours) 

 Physical barriers or fences between work 

areas and the public (includes protective 

barriers in vehicles) 

 Visibility of work areas (e.g. lighting) 

 Cash handling processes (e.g. drop safes) 

 Other______________________________ 

 4 Is your establishment open to the general public? 

 No Î Go to Question 5

 Yes Î (If yes) Select ALL of the hours that your 

establishment is open to the general 

public. 

 Hours between 6 a.m. and 5 p.m.

 Hours between 5 p.m. and 11 p.m.

 Hours between 11 p.m. and 2 a.m.

 Hours between 2 a.m. and 6 a.m.

 5 Select ALL of the hours that employees work at your 

establishment, regardless of whether your 

establishment is open or closed to the general 

public during those times. 

 Hours between 6 a.m. and 5 p.m. 

 Hours between 5 p.m. and 11 p.m. 

 Hours between 11 p.m. and 2 a.m. 

 Hours between 2 a.m. and 6 a.m. 

(If 11 p.m. to 2 a.m. and/or 2 a.m. to 6 a.m. are 

checked) Which of the following procedures 

are used between 11 p.m. and 6 a.m.? 

Check ALL that apply.

 Limited contact with the public (e.g. cash 

and small items exchanged using a passthrough window)

 Minimum of two employees working together 

 Limiting the amount of cash on-hand (e.g. 

drop safes) 

 Escorts to parking areas 

 Employees’ personal alarm systems 

 Security systems (e.g. cameras) 

 Visibility of work areas (e.g. lighting) 

 Other_____________________________ 

 No procedures are used 

Section I: Operations 
3

 6 Which of the following situations apply to 

employees who work at your establishment? 

Check ALL that apply. 

 Working in direct contact with the public 

 Exchanging money with customers 

 Having a mobile workplace (e.g. working out of a 

vehicle) or delivering passengers, goods, or services 

(e.g. taxicab, police cruisers, postal route, or takeout food delivery) 

 Working with unstable or volatile persons in health 

care, social service, or criminal justice settings 

 Working in high crime areas 

 Guarding valuable goods or property (e.g. a 

museum or armored car guard) 

 Working in small numbers (fewer than 5) 

 Working in community-based settings or going doorto-door to residences (e.g. home health care, social 

services, child welfare, or meter readers) 

 Other____________________________________ 

 None of the above 

 7 Do employees at your establishment work alone at 

any time? Examples include a clerk working alone 

at a convenience store, a taxicab driver, a social 

worker making house visits, or a nurse on a ward by 

him or herself. 

 No Î Go to Question 8

 Yes Î (If yes) Which of the following prevention 

strategies are used when this happens? 

Check ALL that apply.

 Limited contact with the public (e.g. 

cash and small items exchanged using 

a pass-through window)

 Limited amount of cash on-hand (e.g. 

drop safes) 

 Escorts to parking areas 

 Personal alarm systems for employees 

 Security systems (e.g. cameras) 

 Visibility of work areas (e.g. lighting) 

 Other_________________________ 

 No prevention strategies are used 

 8 Which of the following are your staff, including 

security staff, authorized to do at your 

establishment? Check ALL that apply. 

 Register or check in visitors before entering the 

office/building 

 Check employees’ badges or IDs before employees 

enter the office/building 

 Stop entry due to restraining/protective orders 

 Use photographs of persons to screen entry of 

possible offenders who may resort to violence 

 Screen calls for victims of harassment or domestic 

violence 

 Have authority to arrest or detain persons for police 

 Have authority to seize weapons 

 Other___________________________________ 

 None of the above 

 9 Does your establishment have a PROCESS OR 

METHOD to identify clients, customers, visitors, 

and/or patients with a history of violence? 

 No 

 Yes 

 10 Does your establishment have a PROCESS OR 

METHOD (e.g. background checks, security 

clearance, employment or personal reference 

checks) to identify potential employees or current 

employees with a history of violence? 

 No 

 Yes 
4

 11 Does your establishment provide additional 

security arrangements (e.g. panic alarms, 

workstation barriers) for employees who have 

been victims of workplace violence? 

 No Î Go to Question 12

 Yes Î (If yes) Which of the following security 

measures does your establishment 

provide? Check ALL that apply.

 Panic alarms 

 Workstation barriers 

 Relocation to another workplace 

(e.g. working at a different location) 

 More secure parking places made 

available 

 Cell phones provided for commute 

or work-related travel 

 Enforcement of 

restraining/protective orders 

 Other_______________________ 

Section II: Programs and Policies 

► Answer questions for ALL employees 

including contractors and subcontractors who 

work for the reporting site. 

 12 Does your establishment have a program or policy 

that includes workplace violence prevention? 

 No Î Go to Question 17

 Yes Î (If yes) Which type of format? Check 

ALL that apply.

 Written program or policy 

 Verbal program or policy 

 13 Which of the following situations does your 

establishment’s workplace violence program or 

policy address? Check ALL that apply. 

 Criminal: when the perpetrator has no legitimate 

relationship to the business or its employees and 

is usually committing a crime in conjunction with 

the violence (e.g. robbery, shoplifting, or 

trespassing). 

 Customer or Client: when the perpetrator has a 

legitimate relationship with the business and 

becomes violent while being served by the 

business (e.g. customers, clients, patients, 

students, inmates, or for any other group that the 

business provides services). 

 Co-Worker: when the perpetrator is an employee, 

past employee of the business, or contractor who 

works as a temporary employee on your site and 

who attacks or threatens another employee. 

 Domestic Violence: when the perpetrator, who 

has no legitimate relationship to the business (but 

has a personal relationship with the intended 

victim), threatens or assaults the employee at the 

workplace (e.g. family member, boyfriend, or 

girlfriend). 
5

 14 Does the program or policy instruct employees 

about how to report concerns or incidents of 

workplace violence? 

 No Î Go to Question 15

 Yes Î (If yes) Which of the following 

reporting methods are included in 

your establishment’s workplace 

violence program or policy? Check 

ALL that apply.

 How employees report incidents 

 How supervisors report incidents 

 How to fill out an incident report form 

 How to access an anonymous “800”, 

toll free, or hotline number 

 Other________________________ 

 15 Does your establishment’s workplace violence 

program or policy address incidents that occur 

outside the workplace but have a workplace 

component or connection (e.g. harassment, 

stalking, physical harm, or verbal threats)? 

 No 

 Yes 

 16 Does your establishment periodically review the 

effectiveness or impact of the workplace violence 

program or policy? 

 No Î Go to Question 17

 Yes Î (If yes) What is included in such a 

review? Check ALL that apply.

 Employee survey 

 Number of violent incidents recorded 

 Costs associated with incidents 

(e.g. worker’s compensation) 

 Other _______________________

 17 Which office or persons are responsible for 

addressing the prevention of workplace violence 

in your establishment? 

 No office or person has this responsibility 

Î Go to Question 19

 Management/Supervisors 

 Designated Employees 

 Union Representatives 

 Employee Assistance Program 

 Human Resources 

 Owner/CEO 

 Security 

 Occupational Safety and Health 

 Risk Management 

 Loss Prevention 

 Other__________________________________ 

 Don’t know Î Go to Question 19

 18 If more than one office or person is responsible, 

who has the PRIMARY responsibility or would take 

the lead in addressing the prevention of workplace 

violence? Check only ONE.

 No single office or person. It’s a shared 

responsibility. 

 Management/Supervisors 

 Designated Employees 

 Union Representatives 

 Employee Assistance Program 

 Human Resources 

 Owner/CEO 

 Security 

 Occupational Safety and Health 

 Risk Management 

 Loss Prevention 

 Other__________________________________ 
6

 19 Does your establishment currently have a 

committee, team, or working group that addresses 

workplace violence prevention? 

 No, but had a committee, team, or working group 

in the past Î Go to Question 20

 No, never had a committee, team, or working 

group Î Go to Question 21

 Yes Î (If yes) Who makes up the workplace 

violence committee, team, or working 

group? Check ALL that apply.

 Management/Supervisors 

 Designated Employees 

 Union Representatives 

 Employee Assistance Program 

 Human Resources 

 Owner/CEO 

 Security 

 Occupational Safety and Health 

 Risk Management 

 Loss Prevention 

 Other _______________________ 

 20 What are or were the functions of the workplace 

violence prevention committee, team, or working 

group? Check ALL that apply.

 Develop an initial workplace violence program or 

policy 

 Raise workplace violence awareness 

 Conduct workplace violence training 

 Establish workplace violence prevention 

strategies 

 Evaluate the workplace for risk factors 

 Recommend additional security measures 

 Maintain security equipment 

 Respond to and/or investigate any workplace 

violence incidents 

 Review all workplace violence reports or 

incidents to identify patterns 

 Other ________________________________ 

Section III: Training 

► Answer questions for ALL employees 

including contractors and subcontractors who 

work for the reporting site. 

 21 Does your establishment provide material on 

workplace violence prevention to employees? 

 No Î Go to Question 22

 Yes Î (If yes) What types of material are 

available? Check ALL that apply.

 Brochures on workplace violence 

prevention 

 Posters on workplace violence 

prevention 

 Newsletters, notices on the Intranet, 

or bulletins in newsletters on 

workplace violence prevention 

 Memo or guidelines regarding how to 

report an incident related to 

workplace violence 

 Memo or guidelines regarding 

security measures (e.g. card keys, ID 

badges) that specifically address 

workplace violence prevention 

 Other _______________________ 

 22 Does your establishment provide training to 

employees on workplace violence prevention, 

even if it is given during company trainings such 

as new employee orientation? 

 No Î Go to Question 26

 Yes Î (If yes) Which of the following topics 

are addressed in your workplace 

violence prevention training? Check 

ALL that apply.

 Workplace violence program or 

policy 

 How to address Domestic Violence 

by a family member, boyfriend, or 

girlfriend at the workplace 

 Risk factors for workplace violence 

(e.g. working alone, working in high 

crime areas) 

 Prevention strategies (e.g. limiting 

the amount of cash on-hand, escorts 

to parking areas) 

 How employees should report 

concerns and incidents of workplace 

violence 

 Other________________________ 
7

 23 During the past 12 months, how many hours of 

training specific to workplace violence prevention 

did EACH employee group receive? 

Check ONE box for each group. 

A. Newly hired employees 

 □

No 

 training 

□

1 hour 

 or less 

□

1-2 

hours 

□

3-4 

hours 

□

5-8 

hours

□

9 or 

more 

hours 

B. Non-supervisory employees

 □

No 

 training 

□

1 hour 

 or less 

□

1-2 

hours 

□

3-4 

hours 

□

5-8 

hours

□

9 or 

more 

hours 

C. Supervisory / managerial employees 

 

 □

No 

 training 

□

1 hour 

 or less 

□

1-2 

hours 

□

3-4 

hours 

□

5-8 

hours

□

9 or 

more 

hours 

D. Contractors / sub-contractors 

□

 No 

such 

 staff 

 □

No 

 training 

□

1 hour 

 or less 

□

1-2 

hours 

□

3-4 

hours 

□

5-8 

hours

□

9 or 

more 

hours 

E. High-risk employees 

Include employees that may be at greater risk of workplace 

violence than other employees (e.g. clerks in convenience 

stores, emergency department staff in hospitals, security guards, 

and receptionists).

□

 No 

such 

 staff 

 □

No 

 training 

□

1 hour 

 or less 

□

1-2 

hours 

□

3-4 

hours 

□

5-8 

hours

□

9 or 

more 

hours 

 24 Which of the following training methods are used 

in your workplace violence training? 

Check ALL that apply. 

•Classroom, instructor led (formal classroom) 

•Self-paced (includes computer-based) 

•On-the-job; one-on-one (informal) 

•Written policies or manuals (references) 

A. Newly hired employees 

 

 □

 No 

 training 

□

Classroom, 

instructor 

 led 

□

Selfpaced 

□

On-thejob; 

one-onone 

□

Written 

policies 

or 

manuals

□

Other 

(list)* 

*Other (list):__________________________________________ 

B. Non-supervisory employees 

 □

 No 

 training 

□

Classroom, 

instructor 

 led 

□

Selfpaced 

□

On-thejob; 

one-onone 

□

Written 

policies 

or 

manuals

□

Other 

(list)* 

*Other (list):__________________________________________ 

C. Supervisory / managerial employees 

 □

 No 

 training 

□

Classroom, 

instructor 

 led 

□

Selfpaced 

□

On-thejob; 

one-onone 

□

Written 

policies 

or 

manuals

□

Other 

(list)* 

*Other (list):__________________________________________ 

D. Contractors / sub-contractors 

□

No 

such 

 staff 

 □

No 

 training 

□

Classroom, 

instructor 

 led 

□

Selfpaced 

□

On-thejob; 

one-onone 

□

Written 

policies 

or 

manuals

□

Other 

(list)* 

*Other (list):__________________________________________

E. High-risk employees 

Include employees that may be at greater risk of workplace violence

than other employees (e.g. clerks in convenience stores, emergency 

department staff in hospitals, security guards, and receptionists).

□

No 

such 

 staff 

 □

 No 

training 

□

Classroom, 

instructor 

 led 

□

Selfpaced 

□

On-thejob; 

one-onone 

□

Written 

policies 

or 

manuals

□

Other 

(list)* 

*Other (list):__________________________________________
8

 25 How often are employees required to participate in 

workplace violence prevention training at your 

establishment? 

 Check ONE box for each group. 

A. Non-supervisory employees 

 □

 Not 

required 

□

One or 

more 

times per 

year 

□

Every 

1-2 

years 

□

Every 

3-5 

years 

□

After an

incident

occurs 

□

Other

(list)*

*Other:_____________________________________________ 

B. Supervisory / managerial employees 

 □

 Not 

required 

□

One or 

more 

times per 

year 

□

Every 

1-2 

years 

□

Every 

3-5 

years 

□

After an

incident

occurs 

□

Other

(list)*

*Other:_____________________________________________ 

C. Contractors / sub-contractors 

□

No 

such 

staff 

 □

 Not 

required 

□

One or 

more 

times per 

year 

□

Every 

1-2 

years 

□

Every 

3-5 

years 

□

After an

incident

occurs 

□

Other

(list)*

*Other:_____________________________________________ 

D. High-risk employees 

Include employees that may be at greater risk of workplace 

violence than other employees (e.g. clerks in convenience 

stores, emergency department staff in hospitals, security guards, 

and receptionists).

□

No 

such 

staff 

 □

 Not 

required 

□

One or 

more 

times per 

year 

□

Every 

1-2 

years 

□

Every 

3-5 

years 

□

After an

incident

occurs 

□

Other

(list)*

*Other:_____________________________________________ 

 26 Does your establishment provide separate training 

on Domestic Violence prevention? 

 No 

 Yes 

Section IV: Reporting 

► Answer questions for ALL employees 

including contractors and subcontractors who 

work for the reporting site. 

 27 During the past 12 months, have employees at 

your establishment experienced any incidents of 

workplace violence, even those that did not result 

in injury? 

 

 No Î Go to Question 32

 Yes Î (If yes) Which of the following types of 

workplace violence incidents 

occurred? Check ALL that apply.

 Criminal: when the perpetrator has 

no legitimate relationship to the 

business or its employees and is 

usually committing a crime in 

conjunction with the violence (e.g. 

robbery, shoplifting, or trespassing). 

 Customer or Client: when the 

perpetrator has a legitimate 

relationship with the business and 

becomes violent while being served 

by the business (e.g. customers, 

clients, patients, students, inmates, 

or for any other group that the 

business provides services). 

 Co-Worker: when the perpetrator is 

an employee, past employee of the 

business, or contractor who works as 

a temporary employee on your site 

and who attacks or threatens another 

employee. 

 Domestic Violence: when the 

perpetrator, who has no legitimate 

relationship to the business (but has 

a personal relationship with the 

intended victim), threatens or 

assaults the employee at the 

workplace (e.g. family member, 

boyfriend, or girlfriend). 
9

 28 When did the most recent incident of workplace 

violence occur? Check only ONE.

 Within the last 30 days 

 1 to 3 months ago 

 4 to 6 months ago 

 7 to 12 months ago 

 29 Did your establishment’s workplace violence 

prevention program or policy change after an 

incident occurred? Check only ONE.

 No 

 Yes 

 No program or policy 

 30 During the past 12 months, have incidents of 

workplace violence....... Check only ONE. 

 Increased 

 Decreased 

 Stayed about the same 

 31 In your opinion, during the past 12 months, has an 

incident of workplace violence affected 

employees at your establishment? 

 No Î Go to Question 32

 Yes Î (If yes) In which of the following ways? 

Check ALL that apply.

 Absenteeism 

 Health insurance premiums 

 Turnover 

 Fear levels 

 Productivity 

 Morale 

 Other_____________________ 

 Don’t know 

 32 Do you think that your establishment is....... 

Check only ONE. 

 Very safe from workplace violence 

 Safe from workplace violence 

 Unsafe from workplace violence 

 Very unsafe from workplace violence 

 Don’t know 

 33 Do you think that your establishment is....... 

Check only ONE. 

 Very safe from crime 

 Safe from crime 

 Unsafe from crime 

 Very unsafe from crime 

 Don’t know 

 34 Do you think that the neighborhood around your 

establishment is....... Check only ONE. 

 Very safe from crime 

 Safe from crime 

 Unsafe from crime 

 Very unsafe from crime 

 Don’t know 

 35 Does your establishment track the cost of 

workplace injuries and illnesses? 

 No 

 Yes

 36 Does your establishment track costs related to 

incidents of workplace violence? 

 No 

 Yes Î (If yes) What types of costs related to 

workplace violence do you track? 

Check ALL that apply.

 Workers’ compensation 

 Third party insurance 

 Absenteeism, accident or 

injury-related leave 

 Replacement workers 

 Property damage 

 Training or prevention costs 

 Other_______________________ 

If you need help in completing our survey or if 

you have questions, please call 202-691-6170 

(not a toll-free number). 

Please return the entire package – everything 

that we sent you – in the enclosed envelope or 

by e-mail within 30 days of the date your 

establishment received it. 

Thank you very much for your help. Your 

cooperation is appreciated.