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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.
To establish a formalized procedure to ensure that resources are available to provide support to all hospital employees who have
recently been assaulted and/or battered.
Each employee who is assaulted and/or battered will have access to treatment and services to manage the trauma.
Assaulted employee: Any employee who is reasonably put in fear of being imminently struck by a patient, either by a menacing
gesture, sudden move alone, or accompanied by a threat.
Battered employee: Any employee who experiences actual physical contact from another (whether or not a
physical injury occurred).
- Assaulted Employee:
- Following an assault, the employee must notify his/her immediate supervisor. The supervisor must complete VA Form 10-2633 on all
- The Supervisor should refer the employee to the Employee Assistance Program. Timely referral, via electronic mail, is encouraged.
- A member of the Employee Assistance Program staff will make contact with the employee to assist the employee with the services
needed which may include: counseling, legal advice, information regarding workmen's' compensation/medical insurance.
- Following an assault, a community meeting must take place on the unit where the assault occurred, including patients and staff to
process the incident as soon as possible.
Hospital Memorandum, 003.07, Patient Injury Control, Preparation of VA Form 10-2633, Report of Special Incident Involving a Beneficiary.
Hospital Memorandum #05.18, "Employee Assistance Program."
Hospital Memorandum #118.13, May 14, 1991.
2. Battered Employee:
- Following an incident whereby an employee is battered, the employee must notify his/her immediate supervisor.
- At the time of the incident, a CA- I form and VA form 2162 must be completed. If the employee is unable to do so, it must be
completed by the supervisor. The supervisor must also complete VA Form 10-2633 on all patient-on-staff assaults.
- The battered employee must report to Employee Health for evaluation and treatment of injuries. If the battery occurs on
non-administrative duty hours, the employee should report to admissions to be evaluated by the O.D.
- Following evaluation and treatment of injuries by Employee Health, the individual is referred by the Employee Health Practitioner
to the Employee Assistance Program. Timely referral, via electronic mail, is encouraged.
- The Employee Assistance Program initiates contact with the battered employee and
- Informs employee of the service available.
- Assists employees in attaining these services such as: counseling, legal advice via police service,
workmen's' compensation and
medical benefits via Personnel Service, etc.
- If a battered employee determines on his or her own to file an application for criminal prosecution with the Concord District Court,
the treating psychiatrist may accompany the employee to court without need for legal process either to an informal hearing before a
clerk-magistrate or a hearing before a judge. The physician may testify to facts known to him. He may not bring VA patient records
unless a court orders them to be produced. The physician may, if asked by the court, offer an opinion regarding the competence or
capacity of the patient to understand the nature of the court's proceedings. The VA psychiatrist may not agree to undertake an
evaluation of the patient in order to report back to the court. These duties may be performed by the court psychiatrist or, in the case
of a period of hospitalization for evaluation, a state hospital. A court order or a request for the presentation of a medical record to
the court must be referred to Medical Administration for Processing.
*This form was taken from: Guidelines for Preventing Workplace Violence for Health Care and Social
Service Workers. OSHA Publication 3148, (1996).
Reprinted with permission of Marilyn Lewis Lanza, D.N.Sc., A.R.N.P., C.S.; Judith Keefe, R.N.; and Margaret Henderson, R.N., M.Ed.,
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA.