Application For Temporary Order For Protection Against Harassment In The Workplace {B-3}

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Case No. ___________________ Dept. No. ___________________ IN THE JUSTICE COURT OF _____________ TOWNSHIP COUNTY OF __________________, STATE OF NEVADA _____________________________________, ) Employer, ) APPLICATION FOR TEMPORARY ) ORDER FOR PROTECTION AGAINST ) HARASSMENT IN THE WORKPLACE ) (NRS 33.250) vs. ) _____________________________________, ) Adverse Party. ) (NOTE: There can only be one Adverse Party.) HARASSMENT IN THE WORKPLACE-- Under NRS 33.240, harassment in the workplace occurs when: 1. A person knowingly threatens to cause or commits an act that causes: (a) Bodily injury to himself or another person; (b) Damage to the property of another person; or (c) Substantial harm to the physical or mental health or safety of a person; 2. The threat is made or the act is committed against an employer, an employee of the employer while the employee performs his duties of employment or a person present at the workplace of the employer; and 3. The threat would cause a reasonable person to fear that the threat will be carried out or the act would cause a reasonable person to feel terrorized, frightened, intimidated or harassed. PLEASE TYPE OR PRINT CLEARLY. COMPLETE THE APPLICATION TO THE BEST OF YOUR KNOWLEDGE. I state the following facts under penalty of perjury: I am the employer. I am the authorized agent of the employer. I am not the employer or authorized agent of the employer. (If this box is checked, you may not file this form.) Form B-3 Application for Temporary Order for Protection Against Harassment in the Workplace Page 1 of 6 ©2007 Nevada Supreme Court June 30, 2007 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 I reasonably believe that the Adverse Party has threatened or committed an act or act(s) of harassment in the workplace as defined above. The event(s) occurred as follows: NOTE: BE SPECIFIC AS TO WHO THREATENED OR COMMITTED WHAT ACT OR ACTS AND AGAINST WHOM. INDICATE APPROXIMATE DATE(S) AND LOCATION(S). ALSO LIST SPECIFIC EMPLOYEE(S)/PERSON(S) PRESENT AT THE WORKPLACE WHO ARE THE FOCUS OF THE HARASSMENT OR WHOM THE ADVERSE PARTY SHOULD BE DIRECTED NOT TO CONTACT. THIS FORM IS A PUBLIC RECORD _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ NOTE: PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES; CHECK BOX IF YOU ARE USING ADDITIONAL PAGES. Check if you use a continuation page (to be incorporated by reference) Form B-3 Application for Temporary Order for Protection Against Harassment in the Workplace Page 2 of 6 ©2007 Nevada Supreme Court June 30, 2007 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 NOTICE REQUIREMENTS (Complete either A or B, not both) A. I HAVE given notice of this Application to the Adverse Party by the following method(s): In Person Telephone E-mail Overnight Carrier Fax First Class Mail Other: __________________________________________________________ Date: ___________________________ Time: _____________________________ I have received confirmation that the Adverse Party has received my Application for a Temporary Order for Protection Against Harassment in the Workplace. Confirmation of receipt is attached (i.e., fax, e-mail, postal mail, etc.). I have not received confirmation. B. I HAVE NOT given notice of this Application to the Adverse Party because immediate and irreparable injury, loss, or damage will result to the employer, an employee of the employer while the employee performs the duties of his employment, or a person who is present at the workplace of the employer, before the matter can be heard on notice. The irreparable injury, loss, or damage that may result is: __________________________________________ It is irreparable because of: Possible economic or property damage which may include the following: ________ ______________________________________________________________________ Continuous threat of stalking/harassment Assault/Battery (personal injury) Possible death to specified individuals named in the Application Other: ______________________________________________________________ 1. What efforts, if any, have been made to give notice to the Adverse Party? _____ _______________________________________________________________________ _______________________________________________________________________ 2. Facts supporting waiver of notice requirements: __________________________ _______________________________________________________________________ _______________________________________________________________________ Form B-3 Application for Temporary Order for Protection Against Harassment in the Workplace Page 3 of 6 ©2007 Nevada Supreme Court June 30, 2007 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 GENERAL INFORMATION 1. a) This matter does not have to be reported to law enforcement; however, has a related report ever been filed? Yes No (Please complete information, if known. You may attach available copies) Approximate date of report(s): _____________________________________________ Name(s) of law enforcement agencies: _______________________________________ Case number(s): ________________________________________________________ b) For purposes of this form, a "TPO Action" is defined to include the following Justice Court actions: (1)