Petition Of Employer For Injunction Prohibiting Violence Or Threats Of Violence Against Employee {WV-0101}

STATE OF INDIANA ) )SS: COUNTY OF ____________) IN THE __________________COURT___ (_______________DIVISION, ROOM___) CASE NO.__________________________ PLAINTIFF: ___________________________________________ DEFENDANT: _________________________________________ EMPLOYEE: __________________________________________ PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE __ Application for Temporary Restraining Order Read the Instructions for Petitions to Prohibit Workplace Violence before completing this form. NOTE: Plaintiff must be an employer with standing to bring this action under IC 34-26-6-4. IMPORTANT: This is a public document and a copy of it will be placed in the Court's file. A copy may also be sent to the Defendant. 1. Plaintiff (name): _____________________________________ is a _ corporation __ sole proprietorship _ other (specify): ___________________________ and is filing this case on behalf of the employee identified in Paragraph 2. Employee (name): ___________________________________ Sex: __ Male __ Female Date of birth: _______________________________ (Use a separate petition for each employee you are seeking to protect.) Defendant (name): _______________________________________ a. Resides at (state address and county):___________________________ _________________________________________________________ b. Works at (state address and county): ___________________________ _________________________________________________________ c. __ Is __ Is not a current employee of plaintiff (explain if defendant is still an employee): _______________________ _________________________________________________________ _________________________________________________________ This case is filed in this county because a. __ defendant resides in this county. b. __ defendant has caused physical or emotional injury to plaintiff's employee in this county. c. __ other (specify): ______________________________________ ___________________________________________________ TCM-WV-0101 Approved 07/02 Rev. by State Ct. Admin. 07/14 American LegalNet, Inc. www.FormsWorkFlow.com 2. 3. 4. Page 1 of _____ pages 5. Defendant has __ battered __ stalked or __ made a credible threat of violence against the employee by knowing or willing statements or 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. a. One of more of these acts can reasonably be construed to be carried out or to have been carried out at the employee's workplace at (address): ___________________________________________________________ ___________________________________________________________ b. Describe what happened (including the dates, who did what to whom, and any injuries): ________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ __ Continued on Attachment 5b. __ Employee will suffer great and irreparable harm before this petition can be heard in court unless the court makes those orders requested below effective now and until the hearing. (Specify the harm and why it will occur before the hearing): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __ Continued on Attachment 6 __ Plaintiff/plaintiff's attorney hereby certifies the following (Check the appropriate box): __ Oral notice of this petition has been given to the defendant. __ Written notice of this petition has been given to the defendant. __ Oral notice of this petition has been given to the defendant's attorney. __ Written notice of this petition has been given to the defendant's attorney. __ A good faith attempt was made to inform the defendant and/or the defendant's attorney of this petition. The efforts to inform consisted of (specify): _________________________________________________ _________________________________________________________ __ Because of the following reasons, plaintiff/plaintiff's attorney should not be required to give notice to the defendant/defendant's attorney (specify): _________________________________________________ _________________________________________________________ _________________________________________________________ Defendant's conduct has been directed against employee and is knowing and willful, is not constitutionally protected, and does not constitute lawful acts of self-defense or defense of others. 6. 7. Page 2 of _____ pages TCM-WV-0101 Approved 07/02 Rev. by State Ct. Admin. 07/14 American LegalNet, Inc. www.FormsWorkFlow.com PLAINTIFF REQUESTS THE COURT TO MAKE THE ORDERS INDICATED BY THE CHECK MARKS IN THE BOXES BELOW. 8. __ RESTRAINING ORDERS __ To be ordered now and effective until the hearing a. Defendant shall not engage in unlawful violence or make threats of violence against the employee and the following members of employee's family or household who reside with the employee: (1) (Name): ____________________________________________ Sex: __ Male __ Female Date of birth: _______________________________ (2) (Name): ____________________________________________ Sex: __ Male __ Female Date of birth: __________________________________ (3) (Name): ____________________________________________ Sex: __ Male __ Female Date of birth: __________________________________ __ Continued on Attachment 8a. b. Specifically, defendant (1) __ shall not batter or stalk the employee and other protected persons. (2) __ shall not follow or stalk the employee and other protected persons to or from the place of work. (3) __ shall not follow the employee and other protected persons during hours of employment. (4) __ shall not contact the employee and other protected persons, directly or indirectly, by any means, including but not limited to, in person, by telephone, in writing, by public or private mail, interoffice mail, by email, by text message, by fax, or by other electronic means. (5) __ shall not enter the workplace of the employee and other protected persons. (6) __ other (specify): ________________________________________ __________________________________________