California Form Wv 100 – Fill Out and Use This PDF

		Petition for Workplace Violence	Clerk stamps date here when form is filed.
	WV-100
		Restraining Orders

2Employee in Need of Protection

Full Name:

Sex: M

F

Age:

3Respondent (Person From Whom Protection Is Sought)

Full Name:							Age:
Address (if known):
City:				State:			Zip:

4Additional 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):

Full Name

Sex

Age Household Member? Relationship to Employee

Yes No

Additional protected persons are listed in Attachment 4a.

This is not a Court Order.

Case Number:

4b. Why do these people need protection? (Explain):

Response is stated in Attachment 4b.

5Relationship of Employee and Respondent

b. Respondent		is	is not a current employee of petitioner. (Explain any decision to retain, terminate,
	or otherwise discipline the respondent):			Response is stated in Attachment 5b.

6Venue

Why are you filing in this county? (Check all that apply):

a. The respondent lives in this county.

b. The respondent has caused physical or emotional injury to the petitioner’s employee in this county.

c. Other (specify):

7Other 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) Workplace Violence

(2) Civil Harassment

(3) Domestic Violence

(4) Divorce, Nullity, Legal Separation

(5) Paternity, Parentage, Child Support

(6) Eviction

(7) Guardianship

(8) Small Claims

(9) Postsecondary School Violence

(10) Criminal

(11) Other (specify):

b. Are any restraining orders or criminal protective orders now 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.

(Workplace Violence Prevention)

Case Number:

8Description 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) Took place at the employee’s workplace

(2)	Can reasonably be construed to be carried out in the future at the employee’s workplace

Address of 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?		Yes	No (If yes, describe harm or injuries):
	Response is stated in Attachment 8d.

This is not a Court Order.

(Workplace Violence Prevention)

Case Number:

8 f. For any of the incidents described above, did the police come?			Yes	✖	No	I don’t know
If yes, did the employee or the respondent receive an Emergency Protective Order?
Yes ✖ No	I don’t know
If yes, the order protects (check all that apply):
the employee	the respondent	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. Harass, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or otherwise), hit, abuse, destroy personal property of, or disturb the peace of the person.

b. Commit acts of unlawful violence on or make threats of violence to the person.

c. Follow or stalk the person during work hours or to or from the place of work.

d. Contact the person, either directly or indirectly, by any means, 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.

e. Enter the person’s workplace.

f. Other (specify):

As stated in Attachment 9f.

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.

10Stay-Away Order

a. I ask the court to order the respondent to stay at least

yards away from (check all that apply):

This is not a Court Order.

(Workplace Violence Prevention)

Case Number:

10b. If the court orders the respondent to stay away from all the places listed above, will he or she still be able to get

to his or her home, school, or job?	Yes ✖ No	(If no, explain):
Response is stated on Attachment 10b.

If the judge grants a protective order, the respondent will be prohibited from owning, possessing, purchasing, receiving, or attempting to purchase or receive a gun, other firearm, and ammunition while the protective order is in effect. The respondent will also be ordered to turn in to law enforcement, or sell to or store with a licensed gun dealer, any guns or firearms within his or her immediate possession or control.

12 Temporary Restraining Order

I request that a Temporary Restraining Order (TRO) be issued against the Respondent to last until the hearing. I am presenting form WV-110, Temporary Restraining Order, for the court’s signature together with this Petition.

Has the Respondent been told that you were going to go to court to seek a TRO against him/her?

Yes No (If you answered no, explain why below):

Reasons are stated in Attachment 12.

13 Request for Less Than Five Days' Notice of Hearing

You must have your papers personally served on the respondent at least five days before the hearing, unless the court orders a shorter time for service. (Form WV-200-INFO explains what is proof of personal service. Form WV-200, Proof of Personal Service, may be used to show the court that the papers have been served.)

If you want there to be fewer than five days between service and the hearing, explain why: Reasons are stated in Attachment 13.

14 No Fee for Filing

I ask that there be no filing fee because the respondent has threatened violence against the employee, or stalked the employee, or acted or spoken in a manner that has placed the employee in reasonable fear of violence.

This is not a Court Order.

(Workplace Violence Prevention)

Case Number:

This is not a Court Order.

(Workplace Violence Prevention)