Workplace Violence Prevention Plan

This Workplace Violence Prevention Plan (“WVPP”) is being implemented by Palo Alto Veterans Institute for Research (“PAVIR”) to help prevent and manage potential workplace violence. This WVPP applies to all PAVIR physical work locations and addresses the hazards known to be associated with the four types of workplace violence as defined by California Labor Code section 6401.9 (see Definitions section).

DEFINITIONS and ACRONYMS

DBC – The multidisciplinary Disruptive Behavior committee at VAPAHCS that reviews DBRS reports.

DBRS – Disruptive Behavior Reporting System. DBRS is VA's secure, facility-wide system for reporting disruptive incidents and enabling multi-disciplinary safety planning.

EAAS - VA Emergency Alerting and Accountability System, the primary method for the VA to send critical information to VA staff members in times of an emergency situation.

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

EOC - VAPAHCS Environment of Care Inspection Team who identify workplace violence hazards and unsafe conditions and work practices.

Log - The violent incident log required by California Labor Code section 6401.9.

PL - VA’s Performance Logic Rounding system, a software tool adopted to standardize EOC Inspection Team rounds across CA medical centers.

Plan - This workplace violence prevention plan (“WVPP”).

POCs - Points of contact that make up the EOC Inspection Team.

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.

TMS – The VA’s Talent Management System, an enterprise learning management platform.

Workplace hazards - Conditions that may lead to workplace violence. Examples of workplace hazards include but are not limited to exterior doors not locking properly, the exterior of the building not being well-lit, erratic and concerning behavior by a colleague, or threats against an employee outside of work that the employee believes could be carried out while they are at work.

VA – U.S. Department of Veterans Affairs

VAPAHCS – VA Palo Alto Healthcare System

Workplace violence - Any act of violence or threat of violence that occurs in the place of employment, meaning in the case of PAVIR employees, the space located on VA property. This Plan does not apply to employees’ regular remote workplaces, which are typically their homes.

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

• The threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury.
• An incident involving a threat or use of a firearm or other dangerous weapon, including the use of common objects as weapons, regardless of whether the employee sustains an injury.
• The following four workplace violence types:
  • Type 1 violence - Workplace violence committed by a person who has no legitimate business at the workplace and includes violent acts by anyone who enters the workplace or approaches employees with the intent to commit a crime.
  • Type 2 violence - Workplace violence directed at employees by customers, clients, or visitors.
  • Type 3 violence - Workplace violence against an employee by a present or former employee, supervisor, or manager.
  • Type 4 violence - Workplace violence committed in the workplace by a person who does not work there but has or is known to have had a personal relationship with an employee.

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

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

RESPONSIBILITY

Those responsible for aspects of this WVPP include:

Responsible Person(s)	Title	WVPP Responsibility(ies)	Contact Information
Lisa Clark	HR Director	WVPP Administrator. The HR Director is the primary plan manager, ensures training is conducted, communicates with employees about the plan, and oversees any reports of workplace violence.	lclark@pavir.org, hr@pavir.org or leadershipteam@pavir.org 650-239-2804
Elaine Staats	CEO	Overall responsibility for the plan. The CEO approves the final plan and any major changes.	estaats@pavir.org or leadershipteam@pavir.org 650-239-2803
VA Palo Alto Healthcare System (VAPAHCS)	Assigned Personnel	Responsible for emergency response and hazard identification. VAPAHCS assigned personnel conduct and direct safety inspections and coordinate emergency response procedures.	Emergencies: Palo Alto: Call ext. 65500 Call 9-911 first and follow up with VA police at ext.56-65891 Call 650-858-3901 Menlo Park: Non-emergencies:
Lisa Clark Nora Thomas	HR Director HR Manager	Responsible for recordkeeping; responsible for employee involvement and training. PAVIR HR staff ensure all records are properly maintained, responds to requests for records, and coordinates employee trainings.	hr@pavir.org 650-239-2804 650-514-6900

The individuals above are responsible for implementing and maintaining PAVIR’s WVPP. If employees have questions about the WVPP, they should submit them to PAVIR’s Human Resources Department via email to hr@pavir.org. Any others designated by the WVPP Administrator to respond to employee questions will consult with the WVPP Administrator as necessary to provide clear and consistent responses to questions.

EMPLOYEE INVOLVEMENT

PAVIR will take the following steps to ensure the active involvement of employees in developing and implementing the WVPP:

• Management will allow employees to participate in:
  • Identifying potential risks and determining corrective measures to prevent workplace violence.
  • Reviewing this plan and providing feedback.
  • Reporting any potential risks or “hazards” they become aware of at any time by contacting PAVIR’s Human Resources Department via email to hr@pavir.org.
  • Providing feedback during the initial training on this WVPP and submitting ideas for or requesting specific topics be addressed during future employee training(s).
  • Designing and implementing future training(s).
  • Reporting and investigating workplace violence incidents. (Reporting any workplace violence you observe or experience is mandatory, even if you are uninjured or, in the case of threats, you don’t believe the threat of violence is serious.)
• Management will provide training and be available to answer questions so that this plan is clearly understood by all employees.
• All employees must follow all WVPP directives, policies, and procedures, and assist in maintaining a safe work environment.
• This plan will be in effect at all times, in all work areas, and will be specific to the potential hazards and corrective measures for each work area.

EMPLOYEE COMPLIANCE

PAVIR’s 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 that create a security hazard for others in the workplace, includes at a minimum:

• Training employees, supervisors, and managers on the provisions of PAVIR’s WVPP at least once per year.
• Providing reminders and updates via email, organization-wide memos, and at staff meetings.
• Requiring additional training for employees who do not follow the WVPP.

Employees who do not comply with the policies and procedures described in this plan are also subject to discipline, up to and including termination, depending on the severity of the violation.

PAVIR will enforce the WVPP rules fairly and uniformly. PAVIR will not tolerate retaliation against an employee who makes a report of workplace violence under this plan.

COMMUNICATION WITH EMPLOYEES

PAVIR recognizes that to maintain a safe, healthy, and secure workplace, two-way communication between management and employees regarding workplace violence, safety, health, and security issues is key. 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:

• PAVIR will conduct regular workplace violence prevention training programs. New employee orientation will include training on workplace violence prevention policies and procedures.
• Addressing workplace violence prevention, such as security issues or potential workplace hazards, at meetings or via email where appropriate.
• The most current version of this WVPP will be posted in the PAVIR Office (Building 101, Rm B4-145) on the corkboard by the entrance next to the labor laws posters. The plan is also available on PAVIR’s website at www.pavir.org
• PAVIR will ensure employees are trained to follow the reporting procedure described below under “Workplace Violence Incident Reporting Procedure”.

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 to the extent legally permissible by the PAVIR Human Resources Department.

OFF-SITE EVENTS AND WORK

PAVIR recognizes that our employees may from time to time attend or present at off-site events sponsored by PAVIR or perform work in off-site locations (not including the employee’s usual remote work location). These other physical spaces are generally not subject to this plan. However, employees who experience an incident of violence while working off-site should still take the following steps: (1) Ensure your own physical safety; (2) call 9-1-1 if there is an ongoing threat; and (3) when it is safe to do so, notify PAVIR of the incident.

• PAVIR will ensure incidents of violence at any PAVIR off-site event involving any employee are investigated and addressed, which may involve coordinating with the host facility or local law enforcement.
• PAVIR employees who experience an incident of violence while working offsite (not in their usual remote work location) should report the incident to PAVIR using the procedure below.

WORKPLACE VIOLENCE INCIDENT REPORTING PROCEDURE

Employees must report all threats or acts of workplace violence to the WVPP Administrator, Lisa Clark, as soon as it is safe to do so. The WVPP Administrator will determine what investigation and other steps are necessary based on the specific threat or act of violence.

• If you believe the threat or act of violence also constitutes harassment or retaliation, you may also report it through the complaint procedure set out in PAVIR’s Employee Handbook.

Employees or their managers must also complete a Workplace Violence Incident Report. The WVPP Administrator or designee will then complete any other reporting and notice requirements.

Additionally, employees or their managers with VA network access must report the incident using the VA’s Disruptive Behavior Reporting System (DBRS). The DBRS, located and accessible on VA computers to all those with VA network usernames, collects information on disruptive incidents, notifies designated staff via email about the incident, provides a standardized management intervention and document system, provides standardized management reporting functions, and allows for appropriate documentation of the incident.

PAVIR will keep the identity of anyone reporting an act or threat of violence as confidential as possible. A violent incident log will be maintained, and employees will be instructed how to obtain copies of records pertaining to hazard identification, evaluation and correction, training records, and violent incident logs.

PAVIR will not retaliate against, and prohibits retaliation against, anyone who makes a report of an incident under this policy. Any employee who retaliates against a reporter in violation of this policy will be subject to discipline, up to and including termination. If a non-employee is retaliating against a reporter, please also immediately report this to PAVIR Human Resources at hr@pavir.org or the WVPP Administrator so it may be addressed.

DISRUPTIVE BEHAVIOR REPORTING SYSTEM (DBRS) GUIDELINES

The VA’s DBRS is only accessible to those with VA network access. PAVIR employees or their managers who have VA network access must report incidents in the DBRS and submit the PAVIR Workplace Violence Incident Report Form, attached hereto as Exhibit A. For those without access, a PAVIR representative will input your report into the DBRS on your behalf.

To use the DBRS:

• Access DBRS on the VA network: Open the DBRS site from a VA workstation or the VA network. DBRS is a facility‑managed web application.
• Start a new report: Select “New Report” (or the equivalent option) to begin documenting the event.
• Identify the individuals involved: Enter names or unique identifiers for the person(s) involved (patient, staff, visitor) and your role as the reporter.
• Describe the event clearly: Provide a factual summary: what happened, where, when, and how. Avoid opinions; focus on observable behavior and direct quotes if applicable.
• Classify the incident: Choose the most accurate incident type/category provided by DBRS (e.g., verbal threats, physical aggression, harassment).
• Add context and contributing factor: Note precipitating events, triggers, or environmental factors (e.g., wait times, pain, confusion), and any de‑escalation steps attempted.
• Record actions taken: Document immediate responses (alerts, notifications, de‑escalation, security involvement) and any medical or safety follow‑up initiated.
• Attach available evidence: Upload supporting materials if allowed (e.g., incident notes). Do not include protected or sensitive information beyond authorized fields.
• Submit and confirm: Review for accuracy, submit the report, and save/record the confirmation number for your records and any required follow‑up.

Complete and submit the report to the best of your ability; a member of the Disruptive Behavior Committee (DBC) committee, which includes representatives from VAPAHCS Patient Safety, Patient Experience, Emergency Management and VA Police, will contact you with questions. Following DBC committee review, PAVIR will have an opportunity to ask questions and then be notified of what actions are taken.

EMERGENCY RESPONSE PROCEDURES

PAVIR has effective means in place to alert employees of the presence, location, and nature of workplace violence emergencies.

If there is immediate danger, employees should report the incident directly by calling:

• Palo Alto: Call ext. 65500. This extension is labeled on all phones and on the cards that hang behind PIV badges.
• Menlo Park: Call 9-911 first and follow up with VA police at ext. 56-65891, if possible, to notify them of 911 call and request escort for external responders.

EMERGENCY ALERT SYSTEM

• PAVIR employees with VA Network access should verify their information for accuracy in the VA Emergency Alerting and Accountability System (EAAS), the primary method for the VA to send critical information to staff members in times of an emergency situation. This system is also used to collect the safety status of staff members so leadership has a clear understanding of who is safe and who may need assistance. Those with VA network access can expect to receive notifications.
• To access the self-service link and update your information in EAAS, go to https://alerts7.athoc.com/SelfService/VAEAAS/SSO. PAVIR employees without VA Network access should communicate with their supervisor to access alert information.
• Active shooter situations at VAPAHCS are communicated through a code alert notification system. Staff are instructed to follow the “Run, Hide, Fight” protocol, respond to overhead announcements and electronic alerts, and coordinate with VA Police and local law enforcement. This notification system ensures rapid communication across the campus, so employees know whether to evacuate, shelter in place, or prepare to defend themselves.

WORKPLACE VIOLENCE HAZARD IDENTIFICATION AND EVALUATION

The following policies and procedures are established and will be implemented by PAVIR to ensure that workplace violence hazards are identified and evaluated:

• Physical inspections of spaces where PAVIR employees work will be conducted in accordance with the semi-annual VAPAHCS inspection schedule and after each workplace violence incident, and whenever the employer is made aware of a new or previously unrecognized hazard.
• PAVIR will review and address all potential hazards identified via inspections. In addition, employees may report concerns of potential hazards, which PAVIR will also review and address, to PAVIR Human Resources at hr@pavir.org.  
• Hazard Correction
• If an imminent workplace violence hazard exists that cannot be immediately abated without endangering employee(s), all exposed employee(s) will be evacuated from the location or ordered to shelter-in-place, whichever appears safest.
• All corrective actions taken will be documented and dated on the appropriate forms.

Any reports received will be reviewed and addressed on a rolling basis.

Periodic Inspections

Semi-annual inspections of workspaces conducted by the VAPAHCS Environment of Care (EOC) Inspection Team for workplace violence hazards will identify unsafe conditions and work practices. The EOC Inspection team includes designated points of contact (POCs) from Safety, Facilities, Infection Control, Occupational Health, Nursing/Clinical Services, and Emergency Management. These inspections are tracked in the VA’s Performance Logic (PL) Rounding center system, a software tool adopted by the VA to standardize EOC rounds across VA medical centers. The inspections may require assessment for more than one type of workplace violence.

Inspections for physical workplace violence hazards include assessing:

• Any need for surveillance measures, such as cameras.
• Posting of most current version of this plan.
• Posting of emergency telephone numbers for law enforcement, fire, and medical services.
• Whether employees carry cell phones or otherwise have access to a phone.
• Whether employees have effective escape routes from the workplace.
• Whether employees have a designated safe area where they can go to in an emergency.
• Adequacy of workplace access security, such as door locks, entry codes or keycard readers.

Hazard Correction

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

• If an imminent workplace violence hazard exists that cannot be immediately abated without endangering employee(s), all exposed employee(s) will be evacuated from the location or ordered to shelter-in-place, whichever appears safest.
• All corrective actions taken will be documented and dated on the appropriate forms.

Corrective measures for workplace violence hazards may be campus(es)-wide, specific to an office or area of an office, or specific to an individual hazard.

POST-INCIDENT RESPONSE AND INVESTIGATION

After a workplace incident, VAPAHCS-designated personnel, in coordination with the WVPP administrator or their designee will implement the following post-incident procedures:

• Visit the scene of an incident as soon as safe and practicable.
• Interview involved parties, such as employees and witnesses, where appropriate and feasible.
• Review security footage of existing security cameras if applicable.
• Inspect the workplace where the incident occurred for security risk factors associated with the incident, including any previous reports of inappropriate behavior by the perpetrator.
• Determine the cause of the incident.
• Take corrective action to prevent similar incidents from occurring.
• Document the findings and ensuring corrective actions are taken.
• Obtain any reports completed by law enforcement.
• Ensure employees are properly supported and have access to counseling or EAP resources as appropriate.
• The PAVIR violent incident reporting form must be used for every workplace violence incident and will document key information about the incident, including:
  • The date, time, and location of the incident.
  • The workplace violence type(s) (as set forth in the Definitions section, above).
  • A detailed description of the incident.
  • Identifying 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. (Final reports will not include names, as discussed in the last paragraph of this section.)
  • A description of the circumstances 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.
  • The location of the incident, such as in the workplace, parking lot or other area outside the workplace, or other area.
  • The type of incident, including, but not limited to, whether it involved any of the following:
    • Physical attack without a weapon, including, but not limited to, biting, choking, grabbing, hair pulling, kicking, punching, slapping, pushing, pulling, scratching, or spitting.
    • Attack with a weapon or object, including, but not limited to, a firearm, knife, or other object.
    • Threat of physical force or threat of the use of a weapon or other object.
    • Sexual assault or threat, including, but not limited to, rape, attempted rape, physical display, or unwanted verbal or physical sexual contact.
    • Animal attack.
    • Other.

• Consequences of the incident, including, but not limited to:
  • Whether security or law enforcement was contacted and their response.
  • Actions taken to protect employees from a continuing threat or from any other hazards identified as a result of the incident.
  • Information about the person completing the log, including their name, job title, and the date completed.

• Reviewing all previous incidents.

No personal identifying information will be recorded or documented in the final draft of the written investigation report, which the WVPP Administrator or their designee will prepare. This includes information which would reveal identification of any person involved in a violent incident, such as the person’s name, address, electronic mail address, telephone number, social security number, or other information that, alone or in combination with other publicly available information, reveals the person’s identity.

TRAINING AND INSTRUCTION

All employees who work onsite, i.e., not remotely, will have training and instruction on general and job-specific workplace violence practices. Training and instruction will be provided as follows:

• When the WVPP is first established.
• Annually to ensure all employees understand and comply with the plan.
• Whenever a new or previously unrecognized workplace violence hazard has been identified and when changes are made to the plan. The additional training may be limited to addressing the new workplace violence hazard or changes to the plan.

Training may be in-person or remote and will be documented by PAVIR.

PAVIR will provide its employees with training and instruction on the definitions and acronyms found at the beginning of this WVPP and the requirements listed below:

• PAVIR’s WVPP, how to obtain a copy of the Plan at no cost, and how to participate in development and implementation of the Plan.
• How to report workplace violence incidents or concerns to PAVIR or law enforcement without fear of reprisal.
• Workplace violence hazards specific to the employees’ jobs, the corrective measures PAVIR has implemented, how to seek assistance to prevent or respond to violence, and strategies to avoid physical harm.
• The violent incident log and how to obtain copies of records pertaining to hazard identification, evaluation and correction, training records, and violent incident logs.
• Opportunities PAVIR has for interactive questions and answers with a person knowledgeable about PAVIR’s plan (Employees will be notified of this opportunity at each training and may also ask questions later of their supervisors or the WVPP Administrator).
• Strategies to avoid/prevent workplace violence and physical harm, such as:
  • Ways to defuse hostile or threatening situations.
  • How to recognize alerts, alarms, or other warnings about emergency conditions and how to use identified escape routes or locations for sheltering.
  • Employee routes of escape.
  • What to do in the event of an active shooter or other ongoing act of violence.
    • VAPAHCS offers a course in the VA Talent Management System (TMS) for active shooter preparedness entitled “Active Threat Response”.

RECORDKEEPING

PAVIR will:

• Create and maintain records of workplace violence hazard identification, evaluation, and correction, for a minimum of five (5) years.
• Maintain records of workplace violence incident investigations for a minimum of five (5) years.
  • The records shall not contain medical information per subdivision (j) of section 56.05 of the California Civil Code.
• Retain Violent Incident Reports for minimum of five (5) years.
• Create and maintain training records for a minimum of one (1) year, including all of the following:
  • Training dates.
  • Contents or a summary of the training sessions.
  • Names and qualifications of persons conducting the training.
  • Names and job titles of all persons attending the training sessions.

All records of workplace violence hazard identification, evaluation, and correction; training, incident logs and workplace violence incident investigations required by California Labor Code section 6401.9(f) will be made available to Cal/OSHA upon request for examination and copying.

EMPLOYEE ACCESS TO WVPP AND RECORDS

PAVIR will post the WVPP in the PAVIR Office (Building 101, Rm B4-145) on the corkboard by the entrance next to the labor laws posters. These plans are also available on PAVIR’s website at www.pavir.org

PAVIR will also make copies of the plan available at no cost to employees who request one. The WVPP will also be available to representatives of Cal/OSHA at all times.

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:

• Records of workplace violence hazard identification, evaluation, and correction.
• Training records.
• Violent incident logs.

EMPLOYER REPORTING RESPONSIBILITIES

As required by California Code of Regulations (CCR), Title 8, Section 342(a). Reporting Work-Connected Fatalities and Serious Injuries, PAVIR 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.

MULTI EMPLOYER COORDINATION

PAVIR employees work across VAPAHCS and other host sites. To ensure safety and compliance, PAVIR coordinates closely with site leadership and security teams.

REVIEW AND REVISION OF THE WVPP AND WORK PRACTICE CONTROLS

• This WVPP will be reviewed for effectiveness:
  • At least annually.
    • When a deficiency is observed or becomes apparent.
    • After a workplace violence incident.

Review and revision of the WVPP will include the procedures to obtain the active involvement of employees in reviewing the plan’s effectiveness, as well as the following procedures:

• Review of incident investigations and the violent incident log.
• Assessment of the effectiveness of security systems, including alarms, emergency response, and access security (keycards, etc.).
• Review that violence risks are being properly identified, evaluated, and corrected. Any necessary revisions are made promptly and communicated to all employees. Such revisions may include changes to procedures, updates to contact information, and additions to training materials.
• Assessment of efficacy in recognizing and handling threatening or hostile situations that may lead to violent acts by clients or coworkers.
• Any possible improvements in management response to incidents; employee participation; employee communication and training; reporting procedures; employee policies related to discharging employees; prohibited conduct, etc.; or measures taken in response to new hazard identification.

VIOLENT INCIDENT REPORT FORM