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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.

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).