Amador — WV-100

Source: https://amador.courts.ca.gov/system/files/forms-and-filings/wv100.pdf

Petition for Workplace Violence Clerk stamps date here when form is filed. WV-100 Restraining Orders 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 sole proprietorship Fill in court name and street address: (specify): 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: Court fills in case number when form is filed. Petitioner’s Address (If the petitioner has a lawyer, give the lawyer’s Case Number: information.) c. Address: City: State: Zip: Telephone: Fax: E-Mail Address: 2 Employee in Need of Protection Full Name: Sex: M F Age: 3 Respondent (Person From Whom Protection Is Sought) Full Name: Age: 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): Full Name Sex Age Household Member? Relationship to Employee Yes No Yes No Yes No

Additional protected persons are listed in Attachment 4a.

This is not a Court Order.

Judicial Council of California, www.courts.ca.gov WV-100, Page 1 of 6Revised January 1, 2018, Mandatory Form Petition for Workplace Violence Restraining Orders Code of Civil Procedure, §§ 527.8 and 527.9 (Workplace Violence Prevention)

Case Number:

b. Why do these people need protection? (Explain): 4 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,
or otherwise discipline the respondent): Response is stated in Attachment 5b.

6 Venue 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):

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) 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.

Revised January 1, 2018 Petition for Workplace Violence Restraining Orders WV-100, Page 2 of 6 (Workplace Violence Prevention)

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) 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.

e. Did the respondent use or threaten to use a gun or any other weapon? Yes No (If yes, describe):
Response is stated in Attachment 8e.

This is not a Court Order.

Revised January 1, 2018 Petition for Workplace Violence Restraining Orders WV-100, Page 3 of 6 (Workplace Violence Prevention)

Case Number:

f. For any of the incidents described above, did the police come? Yes No I don’t know 8
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 þ

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.

10 Stay-Away Order a. I ask the court to order the respondent to stay at least yards away from (check all that apply): (1) The employee. (8) The employee’s vehicle. (2) The other persons listed in 4 . (9) Other (specify): (3) The employee’s workplace. (4) The employee’s home. (5) The employee’s school. (6) The school of the employee’s children. (7) The place of child care of the employee’s children.

This is not a Court Order.

Revised January 1, 2018 Petition for Workplace Violence Restraining Orders WV-100, Page 4 of 6 (Workplace Violence Prevention)

Case Number:

b. If the court orders the respondent to stay away from all the places listed above, will he or she still be able to get10
to his or her home, school, or job? Yes No (If no, explain):
Response is stated on Attachment 10b.

11 Guns or Other Firearms and Ammunition Does the respondent own or possess any guns or other firearms? Yes No I don’t know 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. Revised January 1, 2018 Petition for Workplace Violence Restraining Orders WV-100, Page 5 of 6 (Workplace Violence Prevention)

Case Number:

15 No Fee to Serve Orders I ask the court to order the sheriff or marshal to serve the respondent with the others for free because this request for orders is based on a credible threat of violence or stalking. 16 Court Costs I ask the court to order the respondent to pay my court costs. 17 Additional Orders Requested I ask the court to make the following additional orders (specify): Additional orders requested are stated in Attachment 17.

Number of pages attached to this form, if any:18

Date:

Lawyer’s name (if any) Lawyer’s signature

I declare under penalty of perjury under the laws of the State of California that the information above and on
all attachments is true and correct.
Date:

Name of petitioner Signature

Title

This is not a Court Order.

Revised January 1, 2018 Petition for Workplace Violence Restraining Orders WV-100, Page 6 of 6 (Workplace Violence Prevention) For your protection and privacy, please press the Clear This Form button after you have printed the form. Print this form Save this form Clear this form