Workplace Violence Hazard Identification Form

Atech Logistics & Distribution Workplace Violence Hazard Identification Form
As part of its efforts to mitigate and prevent workplace violence, the company encourages all employees to identify and report potential workplace violence hazards to the company to be evaluated and addressed under the company’s Workplace Violence Prevention Plan (WVPP).

Use this form to identify potential workplace violence hazards specific to your work area, operation or department. Additionally, identify potential corrective measures that the company should consider in addressing the potential hazard. Provide as much detail as possible. When you submit this form it will be routed to the company’s WVPP administrator(s) or other individuals designated to receive such information under the company’s WVPP.
Section 1: Employee Workplace Violence Hazard Identification
Identify any potential workplace violence hazards that may be present in your specific work area, operation or department. Please be specific.*
Identify and describe corrective measures for the company to consider to address the potential workplace violence hazard identified above.
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Name

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You may submit this form anonymously, if preferred. The company will not retaliate against anyone for submitting information concerning workplace violence, including reporting a workplace violence incident, nor will it tolerate or permit retaliation by management, employees or coworkers for submitting such information.
Date*

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Date
Should be Empty:

Atech Logistics & Distribution Workplace Violence Hazard Identification Form

Section 1: Employee Workplace Violence Hazard Identification