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Petition For Workplace Violence Restraining Orders (Workplace Violence Prevention) WV-100 - California
| Petition For Workplace Violence Restraining Orders (Workplace Violence Prevention) Form. This is a California form and can be used in Workplace Violence Judicial Council . |
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WV-100 Petition for Workplace Violence Restraining Orders Clerk stamps date here when form is filed. Read How Do I Get an Order to Prohibit Workplace Violence (Form WV-100-INFO) before completing this form. NOTE: Petitioner must be an employer with standing to bring this action under Code of Civil Procedure section 527.8. Also fill out Confidential CLETS Information (Form CLETS-001) with as much information as you know. 1 Petitioner (Employer) a. Name: is a corporation other (specify): sole proprietorship Fill in court name and street address: Superior Court of California, County of and is filing this suit on behalf of the employee identified in item 2 . b. Lawyer for Petitioner (if any for this case): Name: State Bar No.: Firm Name: Petitioner's Address (If the petitioner has a lawyer, give the lawyer's information.): c. Address: City: Telephone: E-Mail Address: 2 State: Fax: Zip: Court fills in case number when form is filed. Case Number: Employee in Need of Protection Full Name: Sex : M F Age: Age: 3 Respondent (Person From Whom Protection Is Sought) Full Name: Address (if known): City: State: Zip: 4 Additional Protected Persons a. Are you asking for protection for any family or household members of the employee or for any other employees at the employee's workplace or at other workplaces of the petitioner? Yes No If yes, list them. Sex Age Household Member? Relationship to Employee Yes Yes Yes Yes Additional protected persons are listed in Attachment 4a. No No No No Full Name This is not a Court Order. Judicial Council of California, www.courts.ca.gov Revised January 1, 2012, Mandatory Form Code of Civil Procedure, ยงยง 527.8 and 527.9 Petition for Workplace Violence Restraining Orders (Workplace Violence Prevention) WV-100, Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: b. Why do these people need protection? (Explain): Response is stated in Attachment 4b. 5 Relationship of Employee and Respondent a. How does the employee know the respondent? (Describe): Response is stated in Attachment 5a. b. Respondent is is not a current employee of petitioner. (Explain any decision to retain, terminate, Response is stated in Attachment 5b. or otherwise discipline the respondent.) 6 Venue Why are you filing in this county? (Check all that apply): a. The respondent lives in this county. b. c. The respondent has caused physical or emotional injury to petitioner's employee in this county. Other (specify): 7 Other Court Cases a. Has the employee or any of the persons named in 4 been involved in another court case with the respondent? No Yes If yes, check each kind of case and indicate where and when each was filed: Kind of Case Filed in (County/State) Year Filed Case Number (if known) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) Workplace Violence Civil Harassment Domestic Violence Divorce, Nullity, Legal Separation Paternity, Parentage, Child Support Eviction Guardianship Small Claims Postsecondary School Violence Criminal Other (specify): b. Are there now any restraining orders or criminal protective orders in effect relating to the employee or any of the persons in 4 and the respondent? No Yes If yes, attach a copy if you have one. This is not a Court Order. Revised January 1, 2012 Petition for Workplace Violence Restraining Orders (Workplace Violence Prevention) WV-100, Page 2 of 6 Case Number: 8 Description of Respondent's Conduct a. Respondent has (check one or more): (1) Assaulted, battered, or stalked the employee (2) Made a credible threat of violence against the employee by making knowing or willful statements or engaging in a course of conduct that would place a reasonable person in fear for his or her safety or the safety of his or her immediate family b. One or more of these acts (check either or both): (1) (2) Address of workplace: Took place at the employee's workplace Can reasonably be construed to be carried out in the future at the employee's workplace c. Describe what happened. (Provide details; include the dates of all incidents beginning with the most recent; tell who did what to whom; identify any witnesses): Response is stated in Attachment 8c. d. Was the employee harmed or injured? Response is stated in Attachment 8d. Yes No If yes, describe harm or injuries: e. Did the respondent use or threaten to use a gun or any other weapon? Response is stated in Attachment 8e. Yes No If yes, describe: This is not a Court Order. Revised January 1, 2012 Petition for Workplace Violence Restraining Orders (Workplace Violence Prevention) WV-100, Page 3 of 6 Case Number: f. For any of the incidents described above, did the police come? Yes If yes: (1) No I don't know The respondent (3) Yes No I don't know If yes, did the employee or the respondent receive an Emergency Protective Order? The order protects (check all that apply): The employee (2) One or more of the persons in 4 Attach a copy of the order if you have one. Check the orders you want 9 Personal Conduct Orders I ask the court to order the respondent not to do any of the following things to the employee or to any person to be protected listed in 4 : a. b. c. d Harass, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or otherwise), hit, abuse, destroy personal property of, or disturb the peace of the person. Commit acts of unlawful violence on or make threats of violence to the person. Follow or stalk the person during work hours or to or from the place of work. Contact the person, directly or indirectly, in any way, including, but not limited to, in person, by telephone, in writing, by public or private mail, by interoffice mail, by e-mail, by text message, by fax, or by other electronic means. Enter the person's workplace. Other (specify): As stated in Attachment 9f. e. f. The respondent will be ordered not to take any action to get the addresses or locations of any protected person unless the court finds good cause not to make the order. 10 Stay-Away Orders a. I ask the court to order the respondent to stay at least (1) (2) (3) (4) (5) (6) (7) The employee The other persons listed in 4 The employee's workplace The employee's home The employee's school The school of the employee's children The place of child care of the employee's children (8) (9) yards away from (check all that apply): The employee's vehicle Other (specify): This is not a Court Order. Revised January 1, 2012 Petition for Workplace Violence Restraining Orders (Workplace Violence Prevention) WV-100, Page 4 of 6
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