Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Workplace violence Reporting, Investigation & Discipline
Policy Number: 9.58
Effective Date: April 1, 2015
The University of Wisconsin Hospital and Clinics (UWHC) has zero tolerance for workplace violence by
employees. UWHC is committed to providing a safe environment for all persons, including employees,
staff, patients, and visitors.
This policy establishes guidelines and procedures for the prompt reporting, investigation, and resolution
of all allegations of workplace violence.
1. Work place violence is any intentional act, or direct, conditional, implied or veiled threat,
or any other conduct, which harms, or reasonably arouses fear, hostility, intimidation or
the apprehension of harm.
a. Direct Threat: Threats, verbal or written, against a specific target, sometimes
describing the intended act.
b. Conditional Threat: Threats, verbal or written, that are contingent upon a certain
set of circumstances; often use the term "if".
c. Veiled Threat: Threats, verbal or written, that are vague and subject to multiple
2. Violence also includes vandalism or the destruction of property at the worksite belonging
to an employee, patient, vendor, independent contractor or the employer. The employer's
property includes all items owned, leased, or rented.
3. Serious acts or threats of violence include any actual physical acts of violence in
progress, or threats that reasonably induce the belief that physical violence is imminent.
B. Scope: This policy applies to:
1. All UWHC employees, staff, patients, and visitors.
2. Any form of violence on property owned, rented or leased by the UWHC, or operated for
the benefit of the UWHC. This policy also applies to any violence occurring at any other
site, if such violence involves UWHC employees engaged in the performance of their
duties, or if such violence adversely affects the UWHC's legitimate business interests.
3. Domestic violence situations when physical harm, threat of harm or fear of harm creates
a safety issue for any UWHC employee at work. Domestic violence threats at work will
be met with the same level of response as any other kind of violent threat.
C. Prohibited Conduct
1. Prohibited threats and acts of violence include, but are not limited to, the following:
a. Bodily harm/assault or battery, actual or attempted.
b. Sexual assault or battery, actual or attempted.
c. Aggressive, intimidating or threatening behavior (including verbal abuse) or any
other behavior that is intended to or reasonably induces fear, or causes harm to
d. Robbery, actual or attempted.
h. Direct, conditional, or veiled threats to do any of the above.
2. The only persons authorized to have firearms inside UWHC facilities are (1) law
enforcement officers and (2) licensed security officers performing official duties to
service cash machines/ATM’s or provide armored vehicle transport services. No UWHC
employee or any other person may store any explosive devices, firearms or any other
weapon in their vehicles parked in any lot operated by UWHC or the University of
Wisconsin-Madison or leased by UWHC for the use of UWHC’s employees, except that
any persons with a concealed carry permit may keep weapons authorized by such permit
in their own vehicles.
3. Employees or any other person with questions about whether someone is authorized to
carry weapons or firearms on UWHC property should contact Security (890-
5555). Additionally, any questions about whether law enforcement should be notified
should be directed to Security. Security will make the initial contact with any person who
may be in violation of this policy, and Security will contact law enforcement when
appropriate. Employees who contact Security with such questions/concerns should also
notify their supervisors.
4. The State of Wisconsin has determined that personal safety devices, such as pepper spray
are not weapons under sections II.C.2-4 of this policy, but misuse of personal safety
devices can constitute prohibited violence.
1. All violent acts or threats of violence shall be reported immediately to UWHC Security at
2. Employee and Non-Employee Reporting. UWHC employees and all others shall take the
following additional actions when they perceive serious violence is in progress or if a
situation may lead to serious violence.
a. Remove themselves from on-going violence or the threat of immediate violence
as soon as possible.
b. Notify co-workers and management as soon as possible to enable them to take
precautions as necessary.
c. Call 911 by telephone and/or push a panic button if there are immediate threats of
violence. When a panic button is available, it must be pushed firmly to summon
the police. An employee should also call the police via telephone, if possible, to
provide specific details. Employees should remove themselves from the area
until the police give an “all clear”. Employees should also notify Security that
police have been contacted and to report the situation.
d. Counsel all employees identified as potential victims to immediately report any
other acts that may constitute retaliation for their original reports.
e. A Violence/Threat Report Form (available on U-Connect) may be completed by
an employee victim or the employee’s supervisor. Copies should be provided to
UWHC Security, Employee Relations, and the employee’s supervisor. Only one
form should be completed per incident (i.e., multiple reports are not submitted
when there are multiple witnesses).
3. If in doubt whether a situation is workplace violence, UWHC Security should be
contacted at 890-5555.
4. Supervisor Reporting. A supervisor shall immediately confirm that appropriate notice has
been given under III.A.1, 2 & 3 and will also:
a. Notify the appropriate Employee Relations/Human Resources Consultant
(ERC/HRC) in Human Resources and Patient Relations (for those incidents
involving patients or visitors).
b. Notify his or her manager and/or department director.
5. All lesser acts and threats of violence should be reported to Employee Relations in the
Human Resources department at 263-6500 or to the appropriate departmental directors,
managers, and supervisors, and a Violence/Threat form may be completed. For incidents
involving patients or visitors, see Section III.E.
6. After Hours Reporting. Should an incident occur outside normal business hours or during
the weekend, the individual, or their supervisor if present, should immediately contact
UWHC Security, and page his or her supervisor or departmental director (or designees).
a. For serious acts and/or serious threats of violence UWHC Security shall notify
the Nursing Coordinator, Security Director and Administrator-On-Call.
7. Anonymous Threats. Anonymous threats will be taken seriously. Any threats received
will be reported to the appropriate supervisor, UWHC Security and Employee Relations
staff. If an anonymous threat is directed at a specific employee, UWHC Security and the
employee’s supervisor will inform the threatened employee.
8. Domestic Violence/Stalking. Employees who are victims/potential victims of domestic
violence or stalking should report this situation to their supervisor, UWHC Security
and/or Employee Relations.
a. Employees may consider seeking a Temporary Restraining Order against the
abuser/stalker. Copies of Temporary Restraining Orders must be provided to
UWHC Security and Employee Relations and placed on file.
B. Investigations of Incidents Not Involving Patients or Visitors
Investigations and documentation of threatening behavior or violence by independent contractors,
non-UWHC staff, and UWHC employees are the responsibility of Employee Relations staff, and
Risk Management when appropriate, and the department where the incident occurred. The
following procedures will be followed:
1. Preliminary Review
a. A preliminary review will be done by departmental management in conjunction
with the ERC/HRC and/or Risk Management Staff. The supervisor or the
ERC/HRC who receives the report will also alert appropriate management
personnel. The preliminary review should include taking the statement of the
person reporting a violent act and consulting with UWHC Security.
b. After the preliminary review of the information, the department management, in
consultation with Employee Relations will determine if the report warrants
further investigation and who will be the primary investigator.
c. If further investigation is not warranted, the incident report will be retained for a
period of one year by the ERC/HRC and there will be follow-up on any
outstanding issues related to the report.
a. When further investigation is warranted, Employee Relations will either
investigate or supervise a departmental investigation.
b. Forms to guide an investigation, including a Violence/Threat Report Form, are
available from Employee Relations staff in Human Resources.
c. Employee Relations Staff and Department management will be responsible for
ensuring that appropriate personnel procedure requirements are satisfied, where
d. Employee Relations will coordinate investigations with UWHC Security and
e. Upon completion of the investigation, recommendations for future avoidance will
be presented to the Vice President of Human Resources.
f. Persons investigating allegations are responsible for maintaining confidentiality.
g. Individuals who witness or who have knowledge of the occurrence of
inappropriate conduct covered by this policy are expected to cooperate in
h. No one will be disciplined, penalized, coerced, retaliated against, or otherwise
prejudiced for making a good faith report or participating in the investigation of a
i. Victims, witnesses, and alleged offenders will be counseled to report retaliatory
j. Any individual who fails to report a violation of this policy, or who fails to
cooperate with, participate in, or facilitate an investigation or who knowingly
makes a false accusation, may be disciplined, barred from doing business at the
UWHC, or refused services.
k. If the investigation confirms accusations of an occurrence that violates this
policy, then Employee Relations will make a recommendation to management on
the appropriate action.
l. If management takes disciplinary action, victims and witnesses will be advised
that such action will take place. However, these persons will not be advised of
the specific action taken. They will be advised to report retaliatory acts.
m. A disciplined employee will be counseled that any retaliatory acts may lead to
n. A contractor or other non-employee who has violated this policy will be barred
from doing business and/or from the premises.
C. Aftercare Services
Those people directly involved in an incident of workplace violence will have the benefit of
receiving aftercare services. This assistance may take the form of one-on-one counseling, critical
incident stress debriefings, Employee Assistance Program services (see Hospital Administrative
Policy 9.15-Employee Assistance Program), and/or other forms of assistance as deemed
D. Discipline for Acts of Violence by Employees
1. The UWHC will not tolerate violence by its employees. The UWHC considers this
expectation to be fundamental and operates on the premise that no employee requires
counseling to understand this principle.
2. At a minimum, any UWHC employee who is found after investigation to have violated
this policy will receive a formal Letter of Reprimand.
3. Any UWHC employee may be immediately terminated for:
a. Committing a single act of physical violence.
b. Engaging in retaliatory conduct related to a prior act or threat of violence or
report of alleged threats and/or violent acts.
c. Making any credible threat of serious physical violence.
d. Carrying a weapon, firearm or explosive device at work or on a UWHC premises
or parking lots.
4. A UWHC employee may be terminated for any two or more acts of violence of any type.
E. Incidents Involving Patient or Visitors
1. All serious violent acts or serious threats of violent acts shall be reported immediately to
UWHC Security at 890-5555.
2. UWHC employees shall report and document any violent acts or threatening behavior by
or against any patient or visitor through the Patient Safety Net (PSN) pursuant to Hospital
Administrative Policy 4.22-Event Reporting. Investigations of incidents involving
patients or their visitors will be carried out pursuant to Hospital Administrative policy
4.22. The Patient Relations department should also be contacted.
3. If issues of safety involving patients and/or visitors become repeated or ongoing in
nature, Security, Patient Relations (or their designee), Employee Relations, and the
department manager shall conduct a risk assessment and develop a safety plan.
4. If safety cannot be guaranteed, a patient or visitor may be refused services or barred from
the premises for committing acts and/or making threats of violence against UWHC
employees or property, or any other person on UWHC owned or leased property, or in
any situation which adversely affects the UWHC's legitimate business interests.
Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers - OSHA
Publication 3148-01R (2004).
W Admin Code, Chapter COMM 32, Public Employee Safety & Health, June 2002
Dealing with Workplace Violence: A Guide for Agency Planners, OWR-09 (February, 1998).
Violence: Occupational Hazards in Hospitals, DHHS (NIOSH) Publication No. 2002-101(April, 2002)
Hospital Administrative Policy 4.22-Event Reporting
Hospital Administrative Policy 9.15-Employee Assistance Program
Hospital Administrative Policy 9.57-Workplace Violence Planning and Prevention
Sr. Management Sponsors: VP, Human Resources
Author: Director, Employee Relations
Reviewer(s): UWHC Safety Committee; Legal Department; Director, Security
Approval Committee: Administrative Policy and Procedure Committee
President & CEO
Previous revision: 042012
Next revision: 042018