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Application For Temporary 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 Temporary Order For Protection Against Harassment In The Workplace, B-3, 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, ) APPLICATION FOR TEMPORARY
) ORDER FOR PROTECTION AGAINST
) HARASSMENT IN THE WORKPLACE
) (NRS 33.250)
vs.
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)
_____________________________________, )
Adverse Party. )
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(NOTE: There can only be one Adverse Party.)
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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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PLEASE TYPE OR PRINT CLEARLY.
COMPLETE THE APPLICATION TO THE BEST OF YOUR KNOWLEDGE.
I state the following facts under penalty of perjury:
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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
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I reasonably believe that the Adverse Party has threatened or committed an act or act(s) of
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harassment in the workplace as defined above. The event(s) occurred as follows:
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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.
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THIS FORM IS A PUBLIC RECORD
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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_____________________________________________________________________________________________
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NOTE: PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES;
CHECK BOX IF YOU ARE USING ADDITIONAL PAGES.
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͕ Check if you use a continuation page (to be incorporated by reference)
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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
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NOTICE REQUIREMENTS
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(Complete either A or B, not both)
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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.
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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
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GENERAL INFORMATION
1. a) This matter does not have to be reported to law enforcement; however, has a related
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report ever been filed?
Yes
No
(Please complete information, if known. You may attach available copies)
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Approximate date of report(s): _____________________________________________
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Name(s) of law enforcement agencies: _______________________________________
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Case number(s): ________________________________________________________
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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:
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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.
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In the last 2 years, the following TPO action(s) in the State of Nevada have been filed
involving Applicant and the Adverse Party:
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Case #
(if known)
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Court
Place of
(Justice/Family) Filing
Approx.
Date Filed
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Outcome (TPO
granted, denied,
rescinded, etc.)
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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 __________
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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
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3.
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PLEASE CHECK THE APPROPRIATE BOX(ES) BELOW, IF APPLICABLE.
Employee(s) also work at the additional specific locations that need to be enumerated
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in the Order:
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Street Address:________________________________________________________
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Town/City of ____________, County of _______________, State of ____________
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Phone #:_____________________________________________________________
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Street Address:________________________________________________________
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Town/City of ____________, County of _______________, State of ____________
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Phone #:_____________________________________________________________
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(If you wish to designate more specific addresses, please list them in this format on a
separate sheet.)
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The employees perform their duties statewide.
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Other comments on locations where protection is needed: __________________
_______________________________________________________________________
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_______________________________________________________________________
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4.
Authorized agent for employer: ____________________________________________
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5.
Phone number for authorized agent: ________________________________________
6.
Is employer represented by an attorney?
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No
Attorney name: __________________________ Bar #:______________________
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Address: ____________________________________________________________
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Phone # for attorney: ______________ Fax # for attorney: ___________________
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Yes
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Are there additional safety concerns that the Court should know (i.e., firearms, dangerous
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conditions, hazardous premises, nature of business, etc.)?
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If yes, please briefly explain: _______________________________________________
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_______________________________________________________________________
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
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8.
Have there been any other Court actions or any other relationships between the employer
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and the Adverse Party?
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If yes, please describe: ____________________________________________________
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_______________________________________________________________________
No
RELIEF REQUESTED
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Yes
I THEREFORE REQUEST that a Temporary Order for Protection Against Harassment in
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the Workplace be issued against the Adverse Party so that the Adverse Party will be prohibited from
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contacting, intimidating, threatening, or otherwise interfering with the employer’s business and/or its
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employees and/or any person present at the workplace, and that the Adverse Party will be ordered to stay
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away from the employer’s workplace. I also request that the Court prohibit the Adverse Party from
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violating this Order via e-mail, correspondence, telephone, or by an agent.
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I FURTHER REQUEST the following other conditions: __________________________
__________________________________________________________________________________
____________________________________________________________________________________
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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.
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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 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.
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Dated: ___________________________
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__________________________________
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