Skip Navigation

Management Intake Form

When the risk assessment process is initiated to determine the level of risk for violating workplace violence policies, a supervisor, manager or leader who is aware of the incident and the person of concern will be contacted and oriented to the risk assessment process. As part of the triage phase, the team is interested in understanding the report, the context of the situation, precipitating factors, the culture of the work area, and history of behavior and performance. To assist, the department will be asked to complete the Management Intake Form which includes:

  • Description of the event
  • Work history
  • Stressors
  • Work environment/management style
  • Baseline and acute “at-risk” behaviors

Management Intake Form

 
 
List and describe any “at risk” behaviors that are currently present, or have been present in the worksite (including but not limited to: direct verbal threats; “veiled” threats; aggressive/threatening gestures; stalking; threatening or intimidating emails, phone calls, faxes, or notes; physical altercations; destruction of property; suicidal thoughts/gestures; etc.).
 
Describe, in detail, the incident that precipitated the referral for Risk Assessment Evaluation.
 
Describe the employee’s work history at Johns Hopkins, including disciplinary actions, promotions, position changes, etc.
 
Describe stressors present in this workplace (including but not limited to: reorganization, downsizing, RIF’s, transfers, physical moves, labor/management difficulties, change in benefits, accidents, deaths and trauma, staffing changes, management changes, etc.
 
Describe the general workplace environment (including but not limited to: management style; racial, sexual or ethnic issues; general level of acceptable banter; etc.)
 
Do you have any specific questions or concerns that should be addressed by the Risk Assessment Evaluation?
 
Fields marked with * are required.
 
Copyright 2000 Gerald Lewis, PhD
Materials adapted and used with permission by Johns Hopkins Faculty and Staff Assistance Program (FASAP)