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(print the name of the workplace or employer), (Civil Law Self-Help Center)

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© 2020 Nevada Supreme Court Application for Temporary Order for Protection Against
Harassment in the Workplace
Page 1 of 6
JUSTICE COURT IN THE TOWNSHIP OF ___________________________
_______________ COUNTY, NEVADA
_____________________________
________
Employer
(print the name of the workplace or employer),
vs.
_____________________________
________
Adverse Party
(print the name of the person you want
protection from).
CASE NO.: ____________________
DEPT: ____________________
APPLICATION FOR TEMPORARY ORDER FOR PROTECTION
AGAINST HARASSMENT IN THE WORKPLACE
1. Your information (you are the “Applicant”).
Your name: _______________________________________________________________
(first) (middle) (last)
2. Your authority ( check one).
☐I am the employer.
☐I am the authorized agent of the employer.
3. Who do you want protection from (this person is the “Adverse Party”)?
Name: __________________________________________________________________
(first) (middle) (last)
Address (if known):
________________________________________________________
Address City, State, Zip County
4. Are there any other court cases that involve you and the Adverse Party?
☐No
☐Yes. List the case type, county, state, and case number if you know:
© 2020 Nevada Supreme Court Application for Temporary Order for Protection Against
Harassment in the Workplace
Page 2 of 6
5. Most Recent Threat/Harassment.
Think about the most recent threat or harassment. These questions ask about the most
recent incident only.
Approximate date it happened:
City / State / Location where it happened:
Did the other person use or threaten to use a weapon? (a weapon can be a gun, a knife, or
any object that is used to cause or threaten physical harm)?
☐No.
☐Yes (describe what kind of weapon was used or threatened)
Did the police come? ☐No ☐Yes
Was anyone arrested? ☐No ☐Yes: (who?) ___________________________________
Is the adverse party in jail? ☐No ☐Yes
What Happened? Explain the most recent event and describe any injuries. You can list
past events on the next page.
Attach more pages if you need more room (2a, 2b, 2c).
© 2020 Nevada Supreme Court Application for Temporary Order for Protection Against
Harassment in the Workplace
Page 3 of 6
6. Past Threats / Harassment.
Think about any other times the person you want protection from threatened or harassed
you and/or other employees. The following questions ask about any past incidents that may
have happened.
Have there been threats of violence in the past?
☐No (skip to the next page)
☐Yes (complete the sections on this page)
Approximate Date: _____________________
What Happened:
Approximate Date: _____________________
What Happened:
Approximate Date: _____________________
What Happened:
Attach more pages if you need more room (3a, 3b, 3c).
© 2020 Nevada Supreme Court Application for Temporary Order for Protection Against
Harassment in the Workplace
Page 4 of 6
7. Locations that need protecting.
☐ Workplace. The workplace where protection is needed is primarily located at the
following address.
Employer/Location Name
Address
City, State, Zip Code County
☐ Additional Workplace Locations. List the specific locations that employees might
need protection, such as other branches of the workplace or places where employees
perform their duties:
Location Name
Address
City, State, Zip Code County
Location Name
Address
City, State, Zip Code County
☐ Other Places. The adverse party should stay away from the following places.
Location Name
Why?
Address
City, State, Zip Code County
Location Name
Why?
Address
City, State, Zip Code County
8. Have you given the adverse party notice that you are filing this? ( check one and
answer the questions that follow.)
☐ Yes. On the following date, ____________________, I gave notice ( check one or more):
☐in person ☐via email ☐via telephone ☐via mail ☐other: ____________________
© 2020 Nevada Supreme Court Application for Temporary Order for Protection Against
Harassment in the Workplace
Page 5 of 6
☐ No. In order for the judge to grant this without notice, you have to show that giving
notice might cause irreparable, loss, or damage to the employer or employees. Explain why
you should be allowed to skip the notice step.
If you tried to give notice, but were not able to, explain what efforts you made and any facts
that support why you should not have to give notice.
9. Firearms / Guns. Does the adverse party own a gun or have a gun in his/her possession
or control? ☐ No ☐ Yes ☐ I don’t know
10. Other Information: Is there anything else you want the judge to know? Any other
conditions you are asking for?
11. Exhibits: You may attach documents, pictures, or anything else that you would like the
judge to look at and consider when reviewing your application. Note: the adverse party will
be able to see all the exhibits you attach. What exhibits are you attaching?
12. Protections Requested. I request that an Order for Protection Against Harassment in the
Workplace be issued against the Adverse Party so that the Adverse Party will be prohibited
from contacting, intimidating, threatening, or otherwise interfering with the employer’s
business and/or its employees and/or any person present at the workplace, and that the
Adverse Party will be ordered to stay away from the employer’s workplace. I also request
that the Court prohibit the Adverse Party from violating this Order via e-mail,
correspondence, telephone, or by an agent.
© 2020 Nevada Supreme Court Application for Temporary Order for Protection Against
Harassment in the Workplace
Page 6 of 6
13. Length of Protection Order.
This is a 15-day order, do you need an extended order? ☐ No ☐ Yes
If yes, you need to apply before the end of the 15
th
day.
This document does not contain the personal information of any person as defined by
NRS 603A.040.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
DATED _____________________________, 20____.
Submitted By: (your signature)
(print your name)
VERIFICATION
I declare that I am the applicant in the above-entitled action; that I have read the
foregoing application and know the contents thereof; that the pleading is true of my own
knowledge, except for those matters therein contained stated upon information and belief, and
that as to those matters, I believe them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
Submitted By: (your signature)
(print your name)
Attorney /Authorized Agent information:
Name
Address
City, State, Zip Code County
Telephone number
Email address
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Completed 8 January 2021

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