Elementary and Secondary School Employees

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

The National Institute for Occupational Safety and Health (NIOSH) is a part of the United States

Public Health Service and an institute within the Centers for Disease Control and Prevention

(CDC) that is concerned with workplace health and safety. The purpose of this research study is

to measure the prevalence, risk factors, and outcomes of workplace violence in Pennsylvania

K-12 teachers and paraprofessionals. This questionnaire is about your work history as it relates

to incidents of workplace violence. We are interested in obtaining feedback from those who HAVE and those who HAVE NOT experienced violence while on the job. Although participation is entirely voluntary, NIOSH feels it is important for you to complete the questionnaire in order for the study to be successful.

The information you provide NIOSH will be used for statistical and research purposes and will be summarized so that no individual is identified. The information you supply is voluntary and

there is no penalty for not providing it.

“BY COMPLETING THIS QUESTIONNAIRE, YOU INDICATE

YOUR CONSENT TO PARTICIPATE IN THIS STUDY.”

Thank you for your participation.

If you have any questions about the survey, you may contact the NIOSH project officer, Dr. Hope Tiesman at 1(800) XXX-XXXX.

National Institute for Occupational Safety and Health

1095 Willowdale Road, Morgantown, West Virginia 26505-2888

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/xxxx

1. What is your gender? Check one.

1 Male 2 Female

2. What is your date of birth? Please write in date.

(month/day/year)________ / ________ / ________

3. Which of the following best describes your race? Check one or more.

1 American Indian or Alaska Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White

6 Hispanic/Latino of any race

4. What is your current marital status? Check one.

1 Married

2 Living as married/l iving with a domestic partner

3 Never married

4 Separated

5 Divorced

6 Widowed

5. As of today’s date, what is your highest level of education? Check one.

1 Less than a GED/High School Diploma

2 GED

3 High School Diploma

4 Associate Degree

5 Bachelor’s Degree

6 Master’s Degree

7 Education Specialist Degree/Doctorate Degree

6. Please check your one most frequent job duty in the 12 months prior to today’s date. Check one.

1 Classroom teacher (not Special Ed) 8 School Psychologist

2 Special Education Teacher 9 School Social Worker

3 School Nurse 10 Teacher Assistant/Aide

4 Administrator 11 Coach

5 Superintendent/Dean of Students 12 Librarian/Media Specialist

6 Guidance Counselor 13 Security

7 Janitorial Staff/Cafeteria Worker 14 Other position: _____________________

7. What is the total length of time that you have worked in the position/occupation listed above, regardless of where you performed these job duties? Please indicate the number of years and months.

________ year(s) ________month(s)

8. Now, please think of the school you are currently working in. What is the total length of time that you have worked in the school you are currently working in? Please indicate the number of years & months. If you work in multiple schools, please think of the school that you have spent the most time in during the recent school year.

________ year(s) ________month(s)

9. In what type of school did you work the most time in the 12 months prior to today’s date? Check one.

1 Public

2 Public Alternative

3 Public Charter or Public Magnet

4 Private (parochial or non-parochial)

5 No one school type was most common

10. How many students, on average, were enrolled in this school? Check only one.

• Less than 50 students

• 50 to 200 students

• 201 to 500 students

• 501 to 1000 students

• More than 1000 students

11. What was your job classification in this school? Check one.

1 Full-time contract 2 Part-time contract 3 Substitute

12. Please record your best estimate of the number of days worked, and the average number of hours per day you worked in this school during the previous year.

_________ Days in previous year ________Hours per day

If you are a teacher, teacher’s aide, or otherwise directly involved with the education of students, GO TO QUESTION #14 and #15, if not, please continue on to QUESTION 16.

13. What grade level did you teach most frequently in this school? Check one.

1 Kindergarten 8 Seventh Grade

2 First Grade 9 Eighth Grade

3 Second Grade 10 Ninth Grade

4 Third Grade 11 Tenth Grade

5 Fourth Grade 12 Eleventh Grade

6 Fifth Grade 13 Twelfth Grade

7 Sixth Grade 14 Multiple Grades (primary school)

15 Multiple Grades (secondary school)

14. What was your typical class size in this school? Check one.

1 Fewer than 10 4 45 to 54

2 10-24 5 55 or more

3 25 to 44

Physical assault occurs when you are hit, slapped, kicked, pushed, choked, grabbed, sexually assaulted, or subjected to physical contact intended to injure or harm you.

If you experienced single or multiple events, please provide the information for each physical assault that happened to you during the previous 12 months (Event 1-4) below. Start with the event that occurred most recently and complete ‘Event 1’ Column. If more than one event occurred, please go back and complete the ‘Event 2’, ‘Event 3’, and ‘Event 4’ columns as needed.

15. Were you the target of a work-related physical assault at any time during the 12 months prior to today’s date? “Work-related” refers to those events that occur either during your normal work hours, or while you are performing duties related to your position.

• Yes

• N o If NO, go to question 36 on page 8

Event 1	Event 2	Event 3	Event 4
mm/yy -----/----	mm/yy ----/----	mm/yy -----/---	mm/yy ----/-----
1	1	1	1
2	2	2	2
3	3	3	3
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9
1 0	1 0	1 0	1 0
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9

16. Dates of physical assault(s): If unsure of exact date, please give your best estimate.

17. Time(s) of physical assault (s): Check all that apply for each event.

1 During regular school hours

2 Before or after regular school hours

3 Unsure

18. What was (were) the location(s) of the physical assault(s)? Check all that apply for each event.

1 Classroom

2 Hallway/Stairway

3 Parking Area

4 Staff or student lounge

5 Cafeteria

6 Away from school property

7 In a vehicle (bus, etc.)

8 Athletic field/court/gym

9 Extra curricular setting (stage, etc.)

10 Other:____________________________________

19. What was (were) your relationship(s) with the person(s) who physically assaulted you? Check all that apply for each event.

1 Your current student

2 Your former student

3 Another currently enrolled student

4 Another formerly enrolled student

5 Another employee or co-worker

6 Parent

7 Other Authorized Visitor

8 Other Unauthorized Trespasser (Unknown)

9 Other:_________________________________________

Event 1	Event 2	Event 3	Event 4
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
1	1	1	1
2	2	2	2
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6

20. How many total persons were involved with the

physical assault? Check one for each event.

1 One

2 Two

3 Three

4 More than three

21. Were you alone when the attack occurred? Check one for each event.

1 Alone

2 Another teacher or staff member present

22. What was (were) the gender(s) of the person(s) who physically assaulted you? Check one for each event.

1 Male

2 Female

3 Both males and females

4 Unknown

23. In what age group(s) was (were) the person(s) who physically assaulted you? Check all that apply for each event.

1 Age less than nine years

2 Nine years to twelve years of age

3 Thirteen years to fifteen years of age

4 Sixteen years to seventeen years of age

5 Eighteen years of age or older

6 Unsure

24. Was (were) the person(s) who physically assaulted you impaired? Check all that apply for each event.

1 Yes, because of injury, illness, or disability

2 Yes, under influence of alcohol, aerosols, or drugs

3 Not impaired

4 Unsure

25. What object(s) were used by the person(s) who physically assaulted you? Check one for each event.

1 Gun

2 Knife

3 Hands, feet, misc

4 Combination of gun, and/or knife, and/or hands

5 No objects were used

6 Other: ________________________________

Event 1	Event 2	Event 3	Event 4
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9
1 0	1 0	1 0	1 0
1 1	1 1	1 1	1 1
1 2	1 2	1 2	1 2
1 3	1 3	1 3	1 3
1 4	1 4	1 4	1 4
1 5	1 5	1 5	1 5
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9
1 0	1 0	1 0	1 0
1 1	1 1	1 1	1 1
1 2	1 2	1 2	1 2
1 3	1 3	1 3	1 3
1 4	1 4	1 4	1 4
1 5	1 5	1 5	1 5
1 6	1 6	1 6	1 6
1 7	1 7	1 7	1 7
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9
1 0	1 0	1 0	1 0

26. What (were) the type(s) of physical injury? Check

all for each event that apply

1 Abrasion/bruise/contusion

2 Asphyxia/strangulation

3 Bite

4 Burn

5 Concussion (loss of consciousness/awareness)

6 Crushing/mangling

7 Cut/laceration/scratch

8 Fracture/dislocation

9 Nerve Injury

10 Puncture or stabbing

11 Poisoning

12 Sexual Assault

13 Sprain/strain

14 Temporary discoloration/slap mark

15 Other: _________________________________

27. What body part(s) was (were) injured? Check all that apply

1 Head/skull/brain

2 Face (forehead, cheek, nose, lip, chin, ear)

3 Eye/eyelid

4 Teeth/jaw

5 Neck (cervical area)

6 Back (muscles, skin)

7 Chest

8 Spinal cord/spine

9 Abdomen

10 Shoulder/ collar bone, shoulder blade

11 Arm/elbow/wrist

12 Hand/fingers/thumb(s)

13 Hips/pelvis (uterus, ovaries, bladder, rectum)

14 Buttocks/Genitalia

15 Leg (thigh, shin, calf, knee ankle)

16 Foot/heel, toes

17 Other: ___________________________________

28. Were you treated by any of the following as a result of this (these) event(s)? Check all that apply for each event.

1 No treatment

2 Physician (non-Psychiatrist)

3 Dentist

4 Chiropractor

5 Nurse/Nurse Practitioner/ Physician’s Assistant

6 Psychiatrist/Psychologist/Therapist

7 Physical/Occupational Therapist

8 Paramedics/Emergency Medical Technician

9 Homeopathic, Alternative, or Non-traditional provider

10 Other :____________________________________

Event 1	Event 2	Event 3	Event 4
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
1	1	1	1
2	2	2	2
1	1	1	1
2	2	2	2
3	3	3	3
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9
1 0	1 0	1 0	1 0

29 What changes in your work situation occurred as a

result of (these) event(s)? Check all that apply for each event.

1 Quit your job

2 Voluntary transfer to another location

3 Involuntary transfer to another location

4 Leave of absence

5 Restriction of work activities

6 No changes

30. As a result of this (these) event(s), how long were you

absent from work? Check one for each event.

1 Less than four hours

2 Four hours to less than one day

3 One day to two days

4 Three days to six days

5 Seven days to less than a week

6 One week or more

7 No Absence

31. How would you rate the severity of your symptoms or problems resulting from this (these) event(s)? Check one for each event.

1 No limitation of abilities/activities

2 Some limitations of abilities/activities

3 Moderate limitations of abilities/activities

4 Severe limitation of abilities/activities

5 Disabling, inability to function

32. Did you report the event(s) to administration?

1 Yes, orally, written, or electronically (go to 32a)

2 No, I did not report the event (skip to 33)

33 a. If YES, in your opinion, was administration adequately responsive to your report?

1 Yes

2 No

3 Unsure

34. What, in your opinion, was the cause of the physical

assault? Check one for each event.

1 Disciplining a student in the classroom/outside of the

classroom

2 Breaking up a fight

3 Breaking up drug use/drug sales

4 Confronting a visitor or trespasser

5 Dealing with special education students

6 Other (event 1):_________________________________ (event 2):_________________________________

(event 3):_________________________________

(event 4):_________________________________

Please provide the following information for any threats, sexual harassment, verbal abuse or bullying that you experienced during the 12 month’s prior to today’s date

A threat occurs when someone uses words, gestures, or actions with the intent of intimidating, frightening, or causing harm to you (physically or otherwise). Threats may also include theft or property damage.

Sexual harassment occurs when you experience any type of unwelcome sexual behavior (words or actions) that create a hostile work environment.

Verbal Abuse occurs when someone yells or swears at you, calls you names, or uses other words intended to control or hurt you.

Bullying is defined as when one or more people tease, threaten, spread rumors about, hit, shove, or hurt another person over and over again.

35. Did you experience any work-related threats, sexual harassment, verbal abuse, or bullying, according to the above definitions, during the 12 months prior to today’s date? Check one.

• Yes

• Threat	Verbal Abuse	Bullying	Sexual Harassment
  1	1	1	1
  2	2	2	2
  3	3	3	3
  4	4	4	4
  1	1	1	1
  2	2	2	2
  3	3	3	3
  4	4	4	4
  5	5	5	5
  1	1	1	1
  2	2	2	2
  3	3	3	3
  4	4	4	4
  5	5	5	5
  6	6	6	6
  7	7	7	7
  8	8	8	8
  9	9	9	9
  1	1	1	1
  2	2	2	2
  3	3	3	3
  4	4	4	4

  N o If NO, go to question 48 on page 10

36. How frequently did each type of behavior(s) occur?

Check one response per column.

1 1 to 3 times

2 4 to 9 times

3 10 to 19 times

4 20 times or more

37. What was the nature of the behavior(s) (in most

situations)? Check all that apply per column.

1 Physical (gestures, touching, facial expression)

2 Verbal

3 Graphic (picture, email, writing)

4 Theft/destruction of property

5 Other:_______________________________

38. What was your relationship with the person(s) who

threatened/sexually harassed/verbally abused/bullied you

(in most situations)? Check all that apply per column.

1 Your current student

2 Your former student

3 Another currently enrolled student

4 Another formerly enrolled student

5 Another employee

6 Parent

7 Other Authorized Visitor

8 Unauthorized Trespasser (Unknown)

9 Other:________________________________

39. What was (were) the gender(s) of these person(s)?

Check all that apply per column.

1 Male

2 Female

3 Both male and female

4 Unknown

Threat		Verbal Abuse		Bullying	Sexual Harassment
1		1		1	1
2		2		2	2
3		3		3	3
4		4		4	4
5		5		5	5
6	6		6			6
1		1		1	1
2		2		2	2
3		3		3	3
4		4		4	4
1		1		1	1
2		2		2	2
3		3		3	3
4		4		4	4
5		5		5	5
6		6		6	6
7		7		7	7
8		8		8	8
1		1		1	1
2		2		2	2
3		3		3	3
4		4		4	4
5		5		5	5
6		6		6	6
1		1		1	1
2		2		2	2
3		3		3	3
4		4		4	4
5		5		5	5
6		6		6	6
7		7		7	7
1		1		1	1
2		2		2	2

40. In what age group(s) was (were) this (these) person(s)

(in most situations)? Check all that apply per column.

1 Age less than nine years

2 Nine years to twelve years of age

3 Thirteen years to fifteen years of age

4 Sixteen years to seventeen years of age

5 Eighteen years of age or older

6 Unsure

41. Was (were) this(these) person(s) impaired

Check all that apply per column.

1 Yes, because of injury, illness, or disability

2 Yes, under influence of alcohol, aerosols, or drugs

3 Not impaired

4 Unsure

42. Were you treated by any of the following as a result of the behavior(s)? Check all that apply per column.

1 No treatment

2 Physician (non-Psychiatrist)

3 Chiropractor

4 Nurse/Nurse Practitioner/ Physician’s Assistant

5 Psychiatrist/Psychologist/Therapist

6 Physical/Occupational Therapist

7 Homeopathic, Alternative, or Non-traditional provider

8 Other: ___________________________________

43. What changes in your work situation have occurred as a result of the behavior(s)? Check all that apply column.

1 Quit your job

2 Voluntary transfer to another location

3 Involuntary transfer to another location

4 Leave of absence

5 Restriction of work activities

6 No changes

44. As a result of the behavior(s), how many days were

you absent from work? Check one response per column.

1 Less than four hours

2 Four hours to less than one day

3 One day to two days

4 Three days to six days

5 Seven days to less than a week

6 One week or more

7 No Absence

45. Was this violence a single event or was it ongoing in

nature? Check one response per column.

1 Single Event

2 Ongoing Violence

Threat	Verbal Abuse	Bullying	Sexual Harassment
1	1	1	1
2	2	2	2
1	1	1	1
2	2	2	2
3	3	3	3

46. In general, did you report the behavior(s) to

administration? Check all that apply per column.

1 Yes, orally, written or electronically (go to 47a)

2 No, I did not report the event (skip to 48)

47 a. If YES, in your opinion, was administration adequately responsive to your report?

1 Yes

2 No

3 Unsure

______________________________________________________________________________________________________________________________________________________________________________________________________________________

Electronic aggression can occur through words, pictures, or videos and includes someone telling lies, making fun of you through words, pictures or videos, making rude or mean comments, spreading rumors, or making threatening or aggressive comments through email, a cell phone, text messaging, a chat room, instant messaging, or a website (e.g., MySpace, Facebook, YouTube),

Please provide the information for each electronic aggression incident that happened to you during the 12 month’s prior to today’s date . A single incident may be a one time occurrence (e.g., one aggressive text message) or may reflect a related series of electronic aggression (e.g., multiple aggressive text messages). If you experienced more than four un-related incidents, please describe the four that were most distressing to you. If you experienced ongoing electronic aggression, please complete the Event 1 columns regarding how the events occurred and please write in the earliest date the events occurred.

48. Have you been the victim of work-related electronic aggression during the 12 months prior to today’s date? Check YES or NO

□ Yes

□ No If NO, go to question 57 on page 12

49. During the past calendar year how many different

Event 1	Event 2	Event 3	Event 4
1	1	1	1
2	2	2	2
3	3	3	3
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7

incidents of electronic aggression have you been the

victim of?

1. Once

2. Two to four

3. Five or more

50. What mechanism was used to perpetrate the

electronic aggression against you? Check all that apply

(e.g., if something started out as an email, but was then posted

on a website, check “email” and website”)

1. Social networking website (Facebook)

2. Internet chatroom

3. Internet picture or video posting website (YouTube)

4. E-mail or instant message

5. Call to your cell phone

6. Text message to your cell phone

7. Picture or video set to your cell phone

Event 1	Event 2	Event 3	Event 4
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9
1	1	1	1
2	2	2	2
3	3	3	3
4	4	4	4
5	5	5	5
6	6	6	6
7	7	7	7
8	8	8	8
9	9	9	9
1 0	1 0	1 0	1 0
1 1	1 1	1 1	1 1
1 2	1 2	1 2	1 2

51. For each incident, please indicate the type of

electronic aggression you experienced.

1. Lies or rumors spread about you

2. Embarrassing, doctored pictures/videos spread about you

3. Aggressive or threatening comments made toward you

4. Teasing or comments that made fun of you

5 Other: _____________________________________

52. For each incident, please indicate how distressed you were?

1. Very distressed

2. Moderately distressed

3. Slightly distressed

4. Not distressed at all

53. How many days of work were you absent as a

result of each incident?

1 Less than four hours

2 Four hours to less than one day

3 One day to two days

4 Three days to six days

5 Seven days to less than a week

6 One week or more

7 No Absence

54. What was your relationship with the person(s) who perpetrated the incident?

1. Your current student

2. Your former student

3. Another currently enrolled student

4. Another formerly enrolled student

5. Current employee

6. Former employee

7. Parent/grandparent/other student guardian

8. Did not know the person

9. Other: ______________________________

55. How did you respond to the incident? Check all that apply.

1. Told personal friends or family members

2. Told non-administrative co-workers

3. Told someone in the school administration

4. Told someone in the teacher’s union

5. Told someone at the district level (Human Resources)

6. Approached the student directly

7. Responded to the student electronically

8. Spoke to my classes in general about the incident

9. Approached the parents or guardians of the student

10. Sought counseling services (including pastoral)

11. None of the above

12. Other ___________________________________

56. Does your school or school district have any policies that prohibit electronic victimization of teachers and staff using school or non-school owned/leased computers or technology?

1. Yes 2 No 3 Not Sure

57. Does your school or school district have any policies that prohibit electronic victimization of students using school or non-school owned/leased computers or technology?

1. Yes 2 No 3 Not Sure

58. During the past 30 days, how often do you find your work stressful?

1 Always

2 Often

3 Sometimes

4 Hardly Ever

5 Never

59. During the past 30 days, how often have you felt used up at the end of the day?

1 Very Often

2 Often

3 Sometimes

4 Rarely

5 Never

60. During the past 30 days, all in all, how satisfied would you say you are with your job?

1 Very Satisfied

2 Somewhat Satisfied

3 Not too Satisfied

4 Not at all Satisfied

61. During the past 30 days, would you say that in general your health is Excellent, Very good, Good, Fair, or Poor?

1 Excellent

2 Very Good

3 Good

4 Fair

5 Poor

62. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? _________________

63. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? ________

64. During the past 30 days, for about how many days did your poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? __________________

65. Taking everything into consideration, how likely is it you will make a genuine effort to find a new job with another employer within the next year?

1 Very Likely

2 Somewhat Likely

3 Not at all Likely

16