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Employee Security Survey Form

As part of the Cattaraugus County’s effort to provide a safe workplace and minimize the potential for workplace violence, we are requesting your feedback by completing the following survey. Although providing your name is optional, when further clarification would be helpful, it allows us to contact you directly. The information you provide is valuable in assisting the Risk Management Division and the Workplace Violence Prevention Committee in identifying and addressing areas of concern.

If you have any questions then please contact the Cattaraugus County Investigator and/or Safety Engineer of the Risk Management Division.

Employee
Work Location
Employee Name
Other than 8-4, 8:30-4:30, 9-5
Please explain the time(s) that you were working alone that you felt unsafe.
Please explain the times in which you are required to work in isolated areas, where your whereabouts are unknown to co-workers.
Examples of Workplace Violence
Workplace Violence Level 1

The following examples are various types of workplace violence LEVEL ONE. During the past twelve months of your employment, have you been the victim of, or a witness to, any incident(s) of a nature listed below:
Workplace Violence Level 2

The following examples are various types of workplace violence LEVEL TWO. During the past twelve months of your employment, have you been the victim of, or a witness to, any incident(s) of a nature listed below:
Workplace Violence Level 3

The following examples are various types of workplace violence LEVEL THREE. During the past twelve months of your employment, have you been the victim of, or a witness to, any incident(s) of a nature listed below: