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Application For Extended Order For Protection Against Harassment In The Workplace Form. This is a Nevada form and can be use in Workplace Harassment Statewide.
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Tags: Application For Extended Order For Protection Against Harassment In The Workplace, B-13, Nevada Statewide, Workplace Harassment
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Case No. ___________________
Dept. No. ___________________
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IN THE JUSTICE COURT OF _____________ TOWNSHIP
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COUNTY OF __________________, STATE OF NEVADA
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_____________________________________, )
Employer,)
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vs.
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_____________________________________, )
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Adverse Party.
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(NOTE: There can only be one adverse party.)
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APPLICATION FOR EXTENDED
ORDER FOR PROTECTION
AGAINST HARASSMENT IN THE
WORKPLACE (NRS 33.250)
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PLEASE TYPE OR PRINT CLEARLY.
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COMPLETE THE APPLICATION TO THE BEST OF YOUR KNOWLEDGE
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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.
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Applicant states the following facts under penalty of perjury:
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I am the employer or authorized agent of the employer, and I reasonably believe that the Adverse
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Party threatens to cause or commits an act of harassment in the workplace. The Temporary
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Order should be extended for the following reasons:
Form B-13 Application for Extended Order for Protection Against Harassment in the Workplace
Page 1 of 3
©2007 Nevada Supreme Court
June 30, 2007
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Facts from the original Application filed and/or Temporary Order entered in this cause
have been incorporated by reference.
Subsequent or additional acts have 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. THE FACTS YOU
STATE HERE MUST PROVIDE THE BASIS FOR GRANTING AN EXTENDED ORDER
FOR PROTECTION AGAINST HARASSMENT IN THE WORKPLACE.
THIS FORM IS A PUBLIC RECORD
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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-13 Application for Extended Order for Protection Against Harassment in the Workplace
Page 2 of 3
©2007 Nevada Supreme Court
June 30, 2007
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RELIEF REQUESTED
THEREFORE, I REQUEST that an Extended Order for Protection Against Harassment
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in the Workplace be issued against the Adverse Party so that the Adverse Party will be enjoined
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from contacting, intimidating, threatening, or otherwise interfering with the employer’s business
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and/or its employees and/or any person present at the workplace, and that the Adverse Party will
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be ordered to stay away from the employer’s workplace. I also request that the Court prohibit
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the Adverse Party from violating this Order via electronic mail (e-mail), facsimile (fax),
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correspondence, telephone, or through another person.
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I FURTHER REQUEST the following other conditions: ________________________
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__________________________________________________________________________________
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_____________________________________________________________________________
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DECLARATION
(NRS 53.045)
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I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAW OF THE STATE OF
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NEVADA THAT: (1) I AM THE APPLICANT (EMPLOYER OR AUTHORIZED AGENT)
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HEREIN, (2) I HAVE READ THE STATEMENTS CONTAINED HEREIN OR HAVE HAD
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THEM READ TO ME, (3) I BELIEVE THESE STATEMENTS TO BE TRUE, AND (4) THE
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REQUESTED ORDER IS NEEDED.
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_________________________
DATE
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APPLICANT’S SIGNATURE
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PRINT NAME
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Form B-13 Application for Extended Order for Protection Against Harassment in the Workplace
Page 3 of 3
©2007 Nevada Supreme Court
June 30, 2007
