1 2 Case No. ___________________ Dept. No. ___________________ 3 IN THE JUSTICE COURT OF _____________ TOWNSHIP 4 COUNTY OF __________________, STATE OF NEVADA 5 6 7 8 9 _____________________________________, ) Employer, ) APPLICATION FOR TEMPORARY ) ORDER FOR PROTECTION AGAINST ) HARASSMENT IN THE WORKPLACE ) (NRS 33.250) vs. 10 ) _____________________________________, ) Adverse Party. ) 11 (NOTE: There can only be one Adverse Party.) 12 13 14 15 16 17 18 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. 19 20 21 22 23 24 25 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 I reasonably believe that the Adverse Party has threatened or committed an act or act(s) of 2 harassment in the workplace as defined above. The event(s) occurred as follows: 3 4 5 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. 6 7 THIS FORM IS A PUBLIC RECORD 8 _____________________________________________________________________________________________ 9 _____________________________________________________________________________________________ 10 _____________________________________________________________________________________________ 11 _____________________________________________________________________________________________ 12 _____________________________________________________________________________________________ 13 _____________________________________________________________________________________________ 14 _____________________________________________________________________________________________ 15 _____________________________________________________________________________________________ 16 _____________________________________________________________________________________________ 17 _____________________________________________________________________________________________ 18 _____________________________________________________________________________________________ 19 _____________________________________________________________________________________________ 20 _____________________________________________________________________________________________ 21 NOTE: PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES; CHECK BOX IF YOU ARE USING ADDITIONAL PAGES. 22 23 ͕ Check if you use a continuation page (to be incorporated by reference) 24 25 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 NOTICE REQUIREMENTS 3 (Complete either A or B, not both) 4 5 6 7 8 9 10 11 A. I HAVE given notice of this Application to the Adverse Party by the following method(s): In Person E-mail Fax Telephone Overnight Carrier 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. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 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 GENERAL INFORMATION 1. a) This matter does not have to be reported to law enforcement; however, has a related 3 report ever been filed? Yes No (Please complete information, if known. You may attach available copies) 4 Approximate date of report(s): _____________________________________________ 5 6 Name(s) of law enforcement agencies: _______________________________________ 7 Case number(s): ________________________________________________________ 8 9 10 11 12 b) For purposes of this form, a “TPO Action” is defined to include the following Justice Court actions: (1) An Order for Protection Against Stalking and Harassment (NRS 200.591); (2) An Order for Protection of Children (NRS 33.400); (3) An Order for Protection Against Harassment in the Workplace (NRS 33.270). A “TPO Action” is also defined to include the following Justice/Family/District action: (a) An Order for Protection Against Domestic Violence (NRS 33.020) Please Check the Appropriate Box Below: 13 In the last 2 years, Applicant or any party seeking protection has not filed a TPO action against the Adverse Party anywhere in the State of Nevada, and the Adverse Party has not filed a TPO action against Applicant or any party seeking protection anywhere in the State of Nevada. 14 15 16 In the last 2 years, the following TPO action(s) in the State of Nevada have been filed involving Applicant and the Adverse Party: 17 Case # (if known) 18 Court Place of (Justice/Family) Filing Approx. Date Filed 19 Outcome (TPO granted, denied, rescinded, etc.) 20 21 22 23 24 2. a) Employer’s name (if applicable, d/b/a): _____________________________________ b) The workplace is located in, and the employees primarily perform their duties at the following address: ______________________________________________________ Town/City of ________________, County of _______________, State of __________ 25 Phone #:_______________________________________________________________ Form B-3 Application for Temporary Order for Protection Against Harassment in the Workplace Page 4 of 6 ©2007 Nevada Supreme Court June 30, 2007 1 3. 2 PLEASE CHECK THE APPROPRIATE BOX(ES) BELOW, IF APPLICABLE. Employee(s) also work at the additional specific locations that need to be enumerated 3 in the Order: 4 Street Address:________________________________________________________ 5 Town/City of ____________, County of _______________, State of ____________ 6 Phone #:_____________________________________________________________ 7 Street Address:________________________________________________________ 8 Town/City of ____________, County of _______________, State of ____________ 9 Phone #:_____________________________________________________________ 10 (If you wish to designate more specific addresses, please list them in this format on a separate sheet.) 11 The employees perform their duties statewide. 12 13 Other comments on locations where protection is needed: __________________ _______________________________________________________________________ 14 _______________________________________________________________________ 15 4. Authorized agent for employer: ____________________________________________ 16 5. Phone number for authorized agent: ________________________________________ 6. Is employer represented by an attorney? 17 18 No Attorney name: __________________________ Bar #:______________________ 19 Address: ____________________________________________________________ 20 Phone # for attorney: ______________ Fax # for attorney: ___________________ 21 22 Yes 7. Are there additional safety concerns that the Court should know (i.e., firearms, dangerous 23 conditions, hazardous premises, nature of business, etc.)? 24 If yes, please briefly explain: _______________________________________________ 25 _______________________________________________________________________ Form B-3 Application for Temporary Order for Protection Against Harassment in the Workplace Page 5 of 6 Yes No ©2007 Nevada Supreme Court June 30, 2007 1 8. Have there been any other Court actions or any other relationships between the employer 2 and the Adverse Party? 3 If yes, please describe: ____________________________________________________ 4 _______________________________________________________________________ No RELIEF REQUESTED 5 6 Yes I THEREFORE REQUEST that a Temporary Order for Protection Against Harassment in 7 the Workplace be issued against the Adverse Party so that the Adverse Party will be prohibited from 8 contacting, intimidating, threatening, or otherwise interfering with the employer’s business and/or its 9 employees and/or any person present at the workplace, and that the Adverse Party will be ordered to stay 10 away from the employer’s workplace. I also request that the Court prohibit the Adverse Party from 11 violating this Order via e-mail, correspondence, telephone, or by an agent. 12 13 I FURTHER REQUEST the following other conditions: __________________________ __________________________________________________________________________________ ____________________________________________________________________________________ 14 15 16 17 18 I FURTHER REQUEST that this Court set a hearing date for an Extended Order as soon as possible. Yes No If yes, complete the Application for Extended Order for Protection Against Harassment in the Workplace. NOTE: THIS HEARING WILL BE HELD WITHIN TEN (10) JUDICIAL DAYS PURSUANT TO NRS 33.270(6)(c), UNLESS COMPELLING REASONS REQUIRE OTHERWISE. 19 DECLARATION (NRS 53.045) 20 22 I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAW OF THE STATE OF NEVADA THAT: (1) I AM THE EMPLOYER OR AUTHORIZED AGENT HEREIN, (2) I HAVE READ THE STATEMENTS CONTAINED HEREIN OR HAVE HAD THEM READ TO ME, (3) I BELIEVE THESE STATEMENTS TO BE TRUE, AND (4) THE REQUESTED ORDER IS NEEDED. 23 Dated: ___________________________ 21 24 25 __________________________________ SIGNATURE _________________________________ PRINT NAME Form B-3 Application for Temporary Order for Protection Against Harassment in the Workplace Page 6 of 6 ©2007 Nevada Supreme Court June 30, 2007