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Hospital eTool > HealthCare Wide Hazards > Workplace Violence > Confidential Incident Report

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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