A
reportable violent incident should be defined as any threatening
remark or overt act of physical violence against a person(s) or
property whether reported or observed.
1. |
Date:___________________________
Day of week:_____________________
Time:___________________________
Assailant: Female____ Male____ |
|
2.
Specific Location: |
3. |
Violence directed
towards: |
____Patient |
____Staff |
____Visitor |
____Other |
|
Assailant: |
____Patient |
____Staff |
____Visitor |
____Other |
|
Assailant's
Name: _________________________________________ |
|
Assailant: |
____Unarmed |
____Armed
(weapon) |
|
4. |
Predisposing
factors: |
____Intoxication
____Grief reaction
____Gang related |
____Dissatisfied
with care/waiting time
____Prior history of violence |
|
|
____Other
(Describe)_________________________ |
|
|
|
5. |
Description
of incident:
____Physical abuse
____Verbal abuse
____Other |
6.
Injuries:
____Yes
____No |
7.
Extent of Injuries: |
8. Detailed description of the
incident:
9. |
Did
any person leave the area because of incident? |
|
____Yes
____No ____Unable to determine |
10. |
Present at time of
incident: |
11. |
Needed to call: |
|
____Police
__________________Name of department |
|
____Police
__________________Department |
|
____Hospital
security officer |
|
____Hospital
security |
12. |
Termination
of incident:
Incident diffused ____Yes ____No
Police notified ____Yes ____No
Assailant arrested ____Yes
____No |
13. |
Disposition of
assailant: |
14. |
Restraints
used: ____Yes____No |
|
____ Stayed
on premises |
|
|
|
____Escorted
off premises |
|
Type:
_______________________ |
|
____Left
on own
|
|
|
|
____Other
_____________________ |
|
|
15. |
Report
completed by: _____________________ |
Title:
__________________ |
|
Witnesses:
______________________________ |
|
|
Supervisor
notified: _______________________ |
Time:
__________________ |
Please put additional
comments, according to numbered section, on reverse side of form
*This form was taken
from: Guidelines
for Preventing Workplace Violence for Health Care And Social Service
Workers, OSHA Publication 3148, 1996.