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Workplace Violence » Violence Incident Report Form

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.

Date:___________________________
Day of week:_____________________
Time:___________________________
Assailant: Female ____ Male ____

2. Specific Location:
____________________________

Violence directed towards:

____ Patient

____ Staff

____ Visitor

____ Other

Assailant:

____ Patient

____ Staff

____ Visitor

____ Other

Assailant's Name:_________________________________________

Assailant:

____ Unarmed

____ Armed (weapon)

Predisposing factors:

____ Intoxication
____ Grief reaction
____ Gang related

____ Dissatisfied with care/waiting time
____ Prior history of violence

____ Other (Describe) _________________________

Description of incident:
____ Physical abuse
____ Verbal abuse
____ Other

6. Injuries:
____ Yes
____ No

7. Extent of Injuries:
_________________
_________________

8. Detailed description of the incident:

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

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Workplace Violence » Violence Incident Report Form