Application Form - SAFE Employers

Wisconsin's Department of Workforce Development Safe Access For Employees (S.A.F.E.) Employer Application

Basic Information:

Your First Name

Your Last Name

Your Phone Number

Your Email

Name of Company / Business

Your Position in Company/Businness

Other Position

Company Address Line 1

Company Address Line 2

Company City

Company State

Company Zip

Certification Questions (Checking Box Indicates the Statement is True):

1. Your company / business currently has a policy regarding domestic abuse and sexual violence.

2. Your company / business prohibits job discrimination based on an employee's status as a victim of domestic abuse or sexual violence.

3. Your company treats any reports by employees of domestic abuse or sexual violence as private and confidential.

4. Your company provides employees who are dealing with domestic abuse or sexual violence time off work to take care of needs related to domestic abuse or sexual violence, such as seeking legal assistance, attending court proceedings, or relocation.

a. Describe what time off is made available.

5. How are your employees notified of your domestic abuse and sexual violence policy within their first three months of employment?

New Employee Orientation

Employee Handbook

Other

6. Is your policy published for employees to view on request?

a. Where is your policy published?

b. How do employees know where to find the policy?

7. Does your company / business provide any other type of assistance for victims of domestic abuse or sexual violence?

8. Please attach a copy of the relevant policy/policies as .pdf, .doc.