Instructions: the appropriate response under the physical environment/measures & procedures statement Check and/or enter existing controls already in place Enter the recommended controls or actions required who is responsible and date for the recommended control or action to be completed. You are not required to use any of the examples of existing controls. There may be other controls that are more suitable to the circumstances of your workplace and to controlling the risks of workplace violence that you identify. Physical Environment / Measures & Procedures Existing Controls Recommended Controls / Action Person Responsible / Date of Completion 1. Does the public have direct physical access to the workplace? YES NO N/A Counters and/or barriers prevent physical access to non-public areas Equipment is in place to notify workers when someone enters the workplace Reception areas are visible to other workers Signs are posted for worker-only areas Non-workers are accompanied in restricted areas 2. Can workers call for immediate help when required? YES NO N/A Equipment exists that can automatically summons assistance Phones are pre-programmed to dial emergency numbers Emergency numbers are posted by all phones Internal code word(s) are in place to indicate that help is needed 3. Are there objects or equipment on counters in public areas that could be used to hurt people? YES NO N/A Public counters are free of equipment and clutter Sharp and dangerous items are stored so that only workers have access to them 4. Are there designated rooms for meeting with clients? YES NO N/A Meeting room interior is visible to other workers
Meeting room is within hearing range of other workers Meeting room is set up with an easy exit for workers in case of emergency 5. Is a notification system in that alerts workers when a sensitive decision has been made that may increase risk to people in the immediate work area? YES NO N/A Procedures to identify, evaluate, and inform workers about the risk and possible triggers for violence are in place. 6. Are there procedures in place to identify high-risk individuals, situations or locations, and how to respond to aggressive or violent people? YES NO N/A Workers are trained in procedures to identify high risk situations and how to respond Violence prevention measures are reviewed annually with workers Additional Information (if required): Assessment for Specific Risk: 05 - Dealing with Unstable / Volatile Individuals Complete this Specific Risk Assessment if Workplace Activities Include: Providing service to persons with physiological, psychological, or psychiatric conditions, or substance abuse issues Providing service that involves physical contact with clients who may be unpredictable due to influences outside the workplace Instructions: Check the appropriate response under the physical environment/measures & procedures statement Check and/or enter existing controls already in place
Enter the recommended controls or actions required Enter who is responsible and date for the recommended control or action to be completed. You are not required to use any of the examples of existing controls. may be other controls that are more suitable to the circumstances of your workplace and to controlling the risks of workplace violence that you identify. Physical Environment / Measures & Procedures Existing Controls Recommended Controls / Action Person Responsible / Date of Completion 1. Does the public have direct physical access to the workplace? YES NO N/A Counters and/or barriers prevent physical access to non-public areas Equipment is in place to notify workers when someone enters the workplace Reception are visible to other workers are posted for worker-only areas Non-workers are accompanied in restricted 2. Can workers call for immediate help when required? YES NO N/A Equipment exists that can automatically summons assistance Phones are pre-programmed to dial emergency numbers Emergency numbers are posted by all phones Internal code word(s) are in place to indicate that help is needed 3. Are there objects or equipment on counters in public areas that could be used to hurt people? YES NO N/A Public counters are free of equipment and clutter Sharp and dangerous items are stored so that only workers have access to them 4. Are there designated rooms for meeting with clients? YES NO N/A Meeting room interior is visible to other workers Meeting room is within hearing range of other workers Meeting room is set up with an easy exit for workers in case of emergency
You are not required to use any of the examples of existing controls. There may be other controls that are more suitable to the circumstances of your workplace and to controlling the risks of workplace violence that you identify. Physical Environment / Measures & Procedures Existing Controls Recommended Controls / Action Person Responsible / Date of Completion 1. Are safe visit plans in place before workers visit high risk or remote locations? YES NO N/A Safe visit plans are developed for each worker who visits high risk or remote locations Supervisor reviews the safe plan visit with workers prior to visiting high risk or remote locations Safe visit plans are reviewed annually with workers to ensure plans are current 2. Can workers call for immediate help when required? YES NO N/A Equipment exists that can automatically summons assistance Emergency numbers available to all workers Two way radios with direct contact to a dispatcher or co-workers are used Internal code word(s) are in place to indicate that help is needed Procedures in place for contacting 911 3. Do workers work at times of increased vulnerability, such as late at night or early morning? YES NO N/A Buddy system / minimizing number or employees working during higher-risk times Procedures for responding to high risk 4. Are workers provided with the safest route to travel? YES NO N/A A risk assessment has been conducted to identify high crime areas or remote locations and the safest route to travel including parking, walking, public transportation, and hotel recommendations
5. Are vehicles regularly inspected to ensure that they are in good working condition? YES NO N/A Vehicles are checked at the start and end of shift Procedures exist for removing unsafe vehicles Vehicles have scheduled regular maintenance 6. Is there regular contact with workers to check for their safety? YES NO N/A Cell phones/other communication or monitoring devices are provided to workers Regular contact or check-in points in place Designated person monitors contact with workers and follow up if contact is lost 7. Are there procedures in place to identify high-risk individuals, situations or locations, and how to respond to aggressive or violent people? YES NO N/A Workers are trained in procedures to identify high risk situations and how to respond Violence prevention measures are reviewed annually with workers Additional Information (if required):