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The following items serve merely as an example of what might be used or modified by employers to help identify potential workplace violence problems.

Sample 1

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.

(Sample/Draft - Adapt to your own location and business circumstances)

Confidential Incident Report

To:____________________ Date of Incident:_______________
Location of Incident (Map/sketch on reverse side or attached):
___________________________________________________________
From:_______________ Phone:_________ Time of Incident:_______

Nature of the incident: (xx all applicable boxes)
____Assaults or violent acts: ____ Type "1" ____ Type "2" ____ Type "3" ____ Other
____Preventative or warning report
____Bomb or terrorist type threat (special checklists attached Yes or No)
____Transportation accident
____Contacts with objects or equipment
____Falls
____Exposures
____Fires or explosions
____Other

Legal counsel advised of incident
____ Yes ____ No
EAP advised
____ Yes ____ No
Warning or preventative measures
____ Yes ____ No
Number of persons affected ____

(Complete a separate report for each person; however, to the extent facts are duplicative, any person's report may incorporate another person's report.)
Name of affected person(s):
________________________
Service date:______________
Position:__________________________ member of labor organization
____ Yes ____ No
Supervisor:_______________________ has supervisor been notified
____ Yes ____ No
Family:___________________________ has family been notified
____ Yes ____ No

Lost work time ____ Yes ____ No
Anticipated return to work ____
Third parties or non-employee involvement ____ Yes ____ No (include contractor and lease employees, visitors, vendors, customers)

Nature of the incident

Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3) location details; (4) equipment/weapon details; (5) weather; (6) other records of the incident (e.g., police report, recordings, videos); (7) the ability to observe and reliability of witnesses; (8) were the parties possibly impaired because of illness, injury, drugs or alcohol (were tests taken to verify same ____ Yes ____ No); (9) parties notified internally (employee relations, medical, legal, operations, etc.) and externally (police, fire, ambulance, EAP, family, etc.)

Previous or related incidents of this type ____ Yes ____ No
or by this person ____ Yes ____ No
Preventative steps ____ Yes ____ No
OSHA log or other OSHA action required ____ Yes ____ No

Incident Response Team:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Team Leader:____________________ ___________________________
                         Signature                  Date

*Source: Reprinted with permission of Karen Smith Keinbaum, Esq., Counsel to the Law Firm of Abbott, Nicholson, Quilter, Esshaki & Youngblood. P.C., Detroit, MI.


Sample 2

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
  1. Specific Location:_______________
    ______________________________
    ______________________________
    ______________________________

  1. Violence Directed Toward: ____ Patient ____ Staff ____ Visitor ____ Other
    Assailant:                       ____ Patient ____ Staff ____ Visitor ____ Other
    Assailant's Name:________________________________________________
    Assailant:                       ____ Unarmed ____ Armed (weapon)

Predisposing Factors:
  1. ____ Intoxication
    ____ Grief Reaction
    ____ Gang Related
    ____ Other (Describe)
____ Dissatisfied with Care/Waiting Time
____ Prior History of Violence

  1. Description of Incident:
    ____ Physical Abuse
    ____ Verbal Abuse
    ____ Other
  1. Injuries:
    ____ Yes
    ____ No
  1. Extent of Injuries:____________
    ___________________________
    ___________________________

  1. Detailed Description of the Incident:____________________________________
    __________________________________________________________________

  1. Did Any Person Leave the Area because of Incident?
    ____ Yes ____ No ____ Unable to Determine

  1. Present at Time of Incident?
    ____ Police ______________________________ Name of Department
    ____ Hospital Security Officer

  1. Needed to Call:
    ____ Police ______________________________ Name of Department
    ____ Hospital Security

  1. Termination of Incident:

    Incident Diffused
    Police Notified
    Assailant Arrested

____ Yes ____ No
____ Yes ____ No
____ Yes ____ No

  1. Disposition of Assailant:

    Stayed on Premises
    Escorted off Premises
    Left on Own
    Other

____
____
____
____
  1. Restraints Used: ____ Yes ____ No
    Type:_________________________

  1. Report Completed By:________________________ Title:__________________
    Witnesses:________________________________________________________
    Supervisor Notified:___________________________________ Time:_________

Please put additional comments, according to numbered section,
on reverse side of form.


Source: Reprinted with permission of the Metropolitan Chicago Healthcare Council, Guidelines for Dealing with Violence in Health Care, Chicago, IL, 1995.