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300-AQ0-01-IGDO © 2019, Workplace Safety & Prevention Services (WSPS)
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Incidents at Work
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Developing Workplace Violence and Harassment Policies and Programs: A Toolbox
Have you been hit, pushed, physically assaulted, or otherwise attacked while
■ Yes ■ No
working at this organization?
If you answered Yes:
• Where did the incident occur?
• Did you report the incident? ■ Yes ■ No
• How did you report the incident? ■ Orally? ■ In Writing?
• Who physically assaulted or otherwise attacked you?
■ client/customer ■ member of the public ■ co-worker
■ partner/ex-partner ■ manager/supervisor ■ other:
Have you been sexually assaulted or been the target of a sexual incident while ■ Yes ■ No
working at this organization?
If you answered Yes:
• Where did the incident occur?
• Did you report the incident? ■ Yes ■ No
• How did you report the incident? ■ Orally? ■ In Writing?
• Who assaulted you?
■ client/customer ■ member of the public ■ co-worker
■ partner/ex-partner ■ manager/supervisor ■ other:
Have you been threatened with physical harm (orally, in writing, or otherwise) while ■ Yes ■ No
working at this organization?
If you answered Yes:
• Where did the threat occur?
• Did you report the threat? ■ Yes ■ No
• How did you report the threat? ■ Orally? ■ In Writing?
• Who threatened you?
■ client/customer ■ member of the public ■ co-worker
■ partner/ex-partner ■ manager/supervisor ■ other:
WSPS.CA
