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Employee Security Survey Form
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Employee
First Name
Last Name
Job Title
Department
- None -
Administrator's Office
Assigned Council
Aging
Attorney's Office
Attorney's Office › Risk Management
Board of Elections
Buildings & Grounds
Clerk's Office
Clerk's Office › Records Center
Community Services
County Court System
County Government
District Attorney's Office
DMV
Economic Development, Planning and Tourism
Economic Development, Planning and Tourism › Tourism
Economic Development, Planning and Tourism › Planning
Economic Development, Planning and Tourism › Economic Development
Economic Development, Planning and Tourism › Economic Development › Cattaraugus APEX Accelerator
Emergency Services
Emergency Services › Emergency Medical Services
Health Department
Health Department › Childhood Development
Health Department › Emergency Preparedness
Health Department › Environmental Health
Health Department › Home Care
Health Department › Laboratory
Health Department › Preventive
Health Department › Reproductive
Health Department › WIC
Historical Museum & Research Center
Human Resources
Human Resources › Jobs
Information Services
Legislature
The Pines Healthcare and Rehabilitation Centers
NY Connects
One-Stop Career Center
Onoville Marina
Probation
Public Defender
Public Works
Public Works › Weights & Measures
Public Works › Refuse Division
Public Works › Highway Division
Real Property and GIS Services
Sheriff's Office
Social Services
Treasurer's Office
Veterans' Service Agency
Youth Bureau
Work Location
Level I
The following are examples of Level I types of workplace violence.
During the last twelve months of your employment, have you been the victim of, or a witness to, any incident(s) of this nature
None
Verbal Threat
Harassment of any kind
Shouting
Intimidation/bullying
Obscene language/gestures
Incidents
Level II
The following are examples of Level II types of workplace violence.
During the last twelve months of your employment, have you been the victim of, or a witness to, any incident(s) of this nature
None
Threats of assault
Obscene calls
Being followed or stalked
Incidents
Level III
The following are examples of Level III types of workplace violence.
During the last twelve months of your employment, have you been the victim of, or a witness to, any incident(s) of this nature
None
Sexual Assault
Striking with hands or feet
Pushing or grabbing
Shooting
Striking with an object
Assault with biological or chemical material
Stabbing
Incidents
Have you experienced any of the following
(Check all that apply)
Working alone during off hours where you felt unsafe
Working in isolated areas or where your whereabouts are unknown to coworkers
Poor security in and around building and parking lots
Poor lighting in or around building and parking lots
What training do you feel would help create a more productive and safe work environment?
Conflict Resolution
What to do if subjected to workplace violence
How to prevent harassment in the workplace
How to implement effective counseling and corrective discipline
Other Training
(Please specify)
Concerns
