Workplace Violence Reporting Form

Signature Healthcare adheres to a Zero Tolerance standard for workplace violence.

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Date & Time of Incident

At the time of the incident were you an employee, patient or visitor? EmployeePatientVisitor

Location of the Incident

Specific Location of Incident (Garage, hallway, patient room, etc.)

Violence directed toward: PatientStaffVisitorOther

The assailant was: PatientStaffVisitorUnarmedArmed

(Please describe, by selecting all that apply)

Predisposing Factors: Short staffing Drug/alcohol abuseDissatisfied with care waiting timeGrief reactionPrior history of violenceGang relatedUnsure/I don't know

Check all that apply

Description of Incident: Physical abuse/assaultVerbal or written abuseSexual abuse/assaultHarrassmentNonverbalBullying/humiliation

Check all that apply

Additional Narrative/Detailed Description

Were there injuries? YesNoUnsure

Were there witnesses? YesNoUnsure

Who did you notify? SupervisorHospital SecurityPolice

Check all that apply

Disposition of Assailant Stayed on PremisesEscorted from PremisesLeft On Own Unsure/I don't know

What measures do you think could be taken to prevent further incidents of this type?

Please provide your name and contact information if you want us to contact you for additional information and follow up.

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