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 Violence Incident Report Forms*

The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence.

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.

 

 

 

 

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