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Workplace Violence Report
Workplace Violence Report
id
What is your M number?
Did the subject have an altered mental status or behavioral concerns?
Drugs/Alcohol/Withdrawal
Dementia
Alzeimers
Delerium
No - Subject had no behavioral concerns
Yes - Other
Were there any barriers to reporting this incident?
Yes
No
Do you see any areas for improvement?
Training for care team
Security response
Communication on event (shift hand-off)
Delay/Denial in requested intervention (medication)
None of the above
Did you feel comfortable or safe reporting the behavior
Yes
No
Based on follow-up, which of the following BEST describes the main issue that led to this incident?
Nothing provided
Staff decision making
Need better communication
Need better patient handoff
Medications
Adequate staffing
Training needed
Policy/Procedure
Body positioning
Complacentcy
Room dynamics
Did the subject have a Behavioral safety plan in place?
Yes
No
Was a Behavioral Safety Plan (BSP) created for this patient?
Yes
No, but recommended
Unsure
Did the victim seek medical attention after the event?
Yes
No
Was local law enforcement contacted regarding the event?
Yes
No
Is there anything you need from security?
Was an employee incident report (EIR) created?
Yes
No
What behaviors did the victim recognize? Select all that apply
Posturing
Fixation
Threats
Pacing
Refusal
Verbal Cues
Clenching
Quietness
Aggression
Other
At what point did you recognize the escalation?
Behavior change phase
Escalation Phase
Crisis Phase
Post Crisis
N/A
Do you want to press charges?
Yes
no
Contact type?
In person
Email
Phone
Notes
Did the subject have a Behavioral Safety Plan in place?
Yes
No
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