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This is a fillable template that the employer must complete. Complete each of the fields. You must enter your worksite-specific information. After submit, download your WPV Plan. Plan Administrator(s) must sign the Plan below.


Download Cal/Osha Model-WPV-Plan-General-Industry.docx

MODEL WRITTEN WORKPLACE VIOLENCE PREVENTION PLAN FOR GENERAL INDUSTRY (NON-HEALTHCARE SETTINGS)


Cal/OSHA Workplace Violence Prevention Guidance and Resources




* * * * * Enter the name(s), title(s), phone(s), and email(s) for all authorized to carry out the responsibilities for implementing the provisions for this plan. * * * * *






Click Yes If This Employee Is The WVPP Administrator: (Must have at least 1 Admimistrator)
If this person is responsible for periodic inspections, describe the Area, Department, or Specific location:

* * * * * Begin Writing Policy * * * * *

Date of Last Review:
Date of Last Revision(s):

EMPLOYEE ACTIVE INVOLVEMENT

Management will work with and allow employees and authorized employee representatives to participate in: Identifying, evaluating, and determining corrective measures to prevent workplace violence.

Designing and implementing training:

Reporting and investigating workplace violence incidents.

All employees will follow all workplace violence prevention plan directives, policies, and procedures, and assist in maintaining a safe work environment.

EMPLOYEE COMPLIANCE

Our system to ensure that employees comply with the rules and work practices that are designed to make the workplace more secure, and do not engage in threats or physical actions which create a security hazard for others in the workplace, include at a minimum:

Effective procedures to ensure that supervisory and nonsupervisory employees comply with the WVPP.

Recognizing employees who demonstrate safe work practices that promote the WVPP in the workplace by:

Discipline employees for failure to comply with the WVPP. (You can either refer to an existing discipline process or outline specific steps for the WVPP)

COMMUNICATION WITH EMPLOYEES

Effective communication between employees and supervisors about workplace violence prevention and violence concerns:

How employees can report a violent incident, threat, or other workplace violence concern to employer or law enforcement without fear of reprisal or adverse action:

Employees will not be prevented from accessing their mobile or other communication devices to seek emergency assistance, assess the safety of a situation, or communicate with a person to verify their safety. Employees’ concerns will be investigated in a timely manner and they will be informed of the results of the investigation and any corrective actions to be taken.

WORKPLACE VIOLENCE INCIDENT REPORTING PROCEDURE

will implement the following effective procedures to ensure that:

All threats or acts of workplace violence are reported to an employee’s supervisor or manager, who will inform the WVPP administrator. This will be accomplished by:

If that's not possible, employees will report incidents directly to the WVPP administrator:

A strict non-retaliation policy is in place, and any instances of retaliation are dealt with swiftly and decisively:

EMERGENCY RESPONSE PROCEDURES

Effective means to alert employees of the presence, location, and nature of workplace violence emergencies by the following:

will have evacuation or sheltering plans:

How to obtain help from staff, security personnel, or law enforcement:

WORKPLACE VIOLENCE HAZARD IDENTIFICATION AND EVALUATION

Review all submitted/reported concerns of potential hazards:

Periodic Inspections

Periodic inspections of workplace violence hazards will identify unsafe conditions and work practices. This may require assessment for more than one type of workplace violence. Periodic Inspections shall be conducted:

Inspections for workplace violence hazards include assessing:


WORKPLACE VIOLENCE HAZARD CORRECTION

If an imminent workplace violence hazard exists that cannot be immediately abated without endangering employee(s), all exposed employee(s) will be removed from the situation except those necessary to correct the existing condition. Employees necessary to correct the hazardous condition will be provided with the necessary protection.

All corrective actions taken will be documented and dated on the appropriate forms.

Corrective measures for workplace violence hazards will be specific to a given work area.

PROCEDURES FOR POST INCIDENT RESPONSE AND INVESTIGATION

After a workplace incident, the WVPP administrator or their designee will implement the following post-incident procedures:

TRAINING AND INSTRUCTION

Opportunities has for interactive questions and answers with a person knowledgeable about the plan.

EMPLOYEE ACCESS TO THE WRITTEN WVPP

ensures that the WVPP plan shall be in writing and shall be available and easily accessible to employees, authorized employee representatives, and representatives of C al/OSHA at all times. This will be accomplished by:

REVIEW AND REVISION OF THE WVPP

The WVPP will be reviewed for effectiveness:

  • Review that violence risks are being properly identified, evaluated, and corrected. Any necessary revisions are made promptly and communicated to all employees.
  • After clicking 'COMPLETE MY POLICY' your policy will be completed and all data will be erased. Data resides in browser only.



    * * * * * Policy Starts Below * * * * *



    WORKPLACE VIOLENCE PREVENTION PROGRAM for

    Our establishment’s Workplace Violence Prevention Plan (WVPP) addresses the hazards known to be associated with the four types of workplace violence as defined by Labor Code (LC) section 6401.9.

    Date of Last Review:
    Date of Last Revision(s):

    DEFINITIONS

    Emergency - Unanticipated circumstances that can be life threatening or pose a risk of significant injuries to employees or other persons.

    Engineering controls - An aspect of the built space or a device that removes a hazard from the workplace or creates a barrier between the employee and the hazard.

    Log - The violent incident log required by LC section 6401.9.

    Plan - The workplace violence prevention plan required by LC section 6401.9.

    Serious injury or illness - Any injury or illness occurring in a place of employment or in connection with any employment that requires inpatient hospitalization for other than medical observation or diagnostic testing, or in which an employee suffers an amputation, the loss of an eye, or any serious degree of permanent disfigurement, but does not include any injury or illness or death caused by an accident on a public street or highway, unless the accident occurred in a construction zone.

    Threat of violence - Any verbal or written statement, including, but not limited to, texts, electronic messages, social media messages, or other online posts, or any behavioral or physical conduct, that conveys an intent, or that is reasonably perceived to convey an intent, to cause physical harm or to place someone in fear of physical harm, and that serves no legitimate purpose.

    Workplace violence - Any act of violence or threat of violence that occurs in a place of employment.

    Workplace violence includes, but is not limited to, the following:

    Workplace violence does not include lawful acts of self-defense or defense of others.

    Work practice controls - Procedures and rules which are used to effectively reduce workplace violence hazards.

    RESPONSIBILITY

    The WVPP administrator, has the authority and responsibility for implementing the provisions of this plan for . If there are multiple persons responsible for the plan, their roles will be clearly described.

    All managers and supervisors are responsible for implementing and maintaining the WVPP in their work areas and for answering employee questions about the WVPP.

    EMPLOYEE ACTIVE INVOLVEMENT

    ensures the following policies and procedures to obtain the active involvement of employees and authorized employee representatives in developing and implementing the plan:

    EMPLOYEE COMPLIANCE

    Our system to ensure that employees comply with the rules and work practices that are designed to make the workplace more secure, and do not engage in threats or physical actions which create a security hazard for others in the workplace, include at a minimum:

    COMMUNICATION WITH EMPLOYEES

    We recognize that open, two-way communication between our management team, staff, and other employers, about workplace violence issues is essential to a safe and productive workplace. The following communication system is designed to facilitate a continuous flow of workplace violence prevention information between management and staff in a form that is readily understandable by all employees, and consists of one or more of the following:

    COORDINATION WITH OTHER EMPLOYERS

    will implement the following effective procedures to coordinate implementation of its plan with other employers to ensure that those employers and employees understand their respective roles, as provided in the plan.

    WORKPLACE VIOLENCE INCIDENT REPORTING PROCEDURE

    will implement the following effective procedures to ensure that:

    EMERGENCY RESPONSE PROCEDURES

    has in place the following specific measures to handle actual or potential workplace violence emergencies:

    In the event of an emergency, including a Workplace Violence Emergency, contact the following WVPP Administrator:

    WORKPLACE VIOLENCE HAZARD IDENTIFICATION AND EVALUATION

    The following policies and procedures are established and required to be conducted by to ensure that workplace violence hazards are identified and evaluated:

    Periodic Inspections

    Periodic inspections of workplace violence hazards will identify unsafe conditions and work practices. This may require assessment for more than one type of workplace violence. Periodic Inspections shall be conducted:

    Periodic inspections to identify and evaluate workplace violence and hazards will be performed by the following designated personnel in the following areas of the workplace:

    Inspections for workplace violence hazards include assessing:

    WORKPLACE VIOLENCE HAZARD CORRECTION

    Workplace violence hazards will be evaluated and corrected in a timely manner. will implement the following effective procedures to correct workplace violence hazards that are identified:

    PROCEDURES FOR POST INCIDENT RESPONSE AND INVESTIGATION

    After a workplace incident, the WVPP administrator or their designee will implement the following post-incident procedures:

    TRAINING AND INSTRUCTION

    All employees, including managers and supervisors, will have training and instruction on general and job-specific workplace violence practices. These sessions could involve presentations, discussions, and practical exercises. Training and instruction will be provided as follows:

    will provide its employees with training and instruction on the definitions found on page 1 of this plan and the requirements listed below:

    Note: Employers must use training material appropriate in content and vocabulary to the educational level, literacy, and language of employees.

    EMPLOYEE ACCESS TO THE WRITTEN WVPP

    ensures that the WVPP plan shall be in writing and shall be available and easily accessible to employees, authorized employee representatives, and representatives of Cal/OSHA at all times. This will be accomplished by:

    RECORDKEEPING

    will:

    EMPLOYEE ACCESS TO RECORDS

    The following records shall be made available to employees and their representatives, upon request and without cost, for examination and copying within 15 calendar days of a request:

    REVIEW AND REVISION OF THE WVPP

    The WVPP will be reviewed for effectiveness:

    Review and revision of the WVPP will include the procedures listed in the EMPLOYEE ACTIVE INVOLVEMENT section of this WVPP, as well as the following procedures to obtain the active involvement of employees and authorized employee representatives in reviewing the plan’s effectiveness:

    EMPLOYER REPORTING RESPONSIBILITIES

    As required by California Code of Regulations (CCR), Title 8, Section 342(a). Reporting Work-Connected Fatalities and Serious Injuries, will immediately report to Cal/OSHA any serious injury or illness (as defined by CCR, Title 8, Section 330(h)), or death (including any due to Workplace Violence) of an employee occurring in a place of employment or in connection with any employment.

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    Workplace Violence Prevention Plan Authorization

    Name and title of person authorizing this WVPP:
    Name: Title:
    Signature of person authorizing this WVPP:
    Signature: Date:

    * * * * * END OF POLICY * * * * *


    Violent Incident Log

    This log must be used for every workplace violence incident that occurs in our workplace. At a minimum, it will include the information required by LC section 6401.9(d).

    The information that is recorded will be based on:

    All information that personally identifies the individual(s) involved will be omitted from this log, such as:

    Incident Date [Enter the date the incident occurred (Day, Month, Year)]
    Incident Time [Enter the time (or approximate time) that the incident occurred] a.m./p.m.
    Location(s) of Incident [Enter location(s) where the incident occurred]
    Workplace Violence Type [Enter the workplace violence type(s) (Type 1, 2, 3, 4)]

    Check which of the following describes the type(s) of incident, and explain in detail:

    Note: It’s important to understand that “Workplace Violence Type” and “Type of Incident” have separate requirements. For this part of the log, “Type of Incident” specifically refers to the nature or characteristics of the incident being logged. It does not refer to the type of workplace violence.

    Explain: [Provide a detailed description of the incident and any additional information on the violence incident type and what it included. Continue on separate sheet of paper if necessary.]

     
     
     
     

    Workplace violence committed by:

    [For confidentiality, only include the classification of who committed the violence, including whether the perpetrator was a client or customer, family or friend of a client or customer, stranger with criminal intent, coworker, supervisor or manager, partner or spouse, parent or relative, or other perpetrator.]

    Circumstances at the time of the incident:

    [write/type what was happening at the time of the incident, including, but not limited to, whether the employee was completing usual job duties, working in poorly lit areas, rushed, working during a low staffing level, isolated or alone, unable to get help or assistance, working in a community setting, or working in an unfamiliar or new location.]

     
     
     
     

    Where the incident occurred:

    [Where the incident occurred, such as in the workplace, parking lot or other area outside the workplace, or other area.]

     
     
     
     

    Consequences of the incident, including, but not limited to:

    [Include information on what the consequences of the incident were.]

     
     
     
     

    Were there any injuries? Yes or No. Please explain:

    [Indicate here if there were any injuries, if so, provide description of the injuries]

     
     
     
     

    Were emergency medical responders other than law enforcement contacted, such as a Fire Department, Paramedics, On-site First-aid certified personnel? Yes or No. If yes, explain below:

     
     
     
     

    Did the severity of the injuries require reporting to Cal/OSHA? If yes, document the date and time this was done, along with the name of the Cal/OSHA representative contacted.

     
     
     
     

    A copy of this violent incident log needs to be provided to the employer. Indicate when it was
     
     
     
     

    This violent incident log was completed by:

    [Name of person completing this log], [Job Title of person completing this log], [Date this log was completed]

    [Signature of person completing this log] [Date of completion]