Evaluation Form

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

EVALUATION OF HOSPITAL WORKPLACE VIOLENCE PREVENTION PROGRAM: ABSTRACTION FORM

Check if hospital has:  Emergency Department: # patients/year: _______

 Psychiatric Unit(s): # beds: _______

Voluntary Adm: Y/N Involuntary Adm: Y/N

 Detox Unit (stand-alone): # beds: _______

A. WORKPLACE VIOLENCE PREVENTION PROGRAM

1. Does the hospital have a formal written workplace violence prevention plan?

01 Yes 02 No 99 Unknown

If YES:

2. Does the workplace violence prevention plan directly address?

a. Establishment of a violence prevention committee	Yes No
b1. Worker-on-worker violence b2. Patient/family violence against workers b3. Domestic violence (where the victim is an employee) that enters the hospital b4. Criminal activity in and around the hospital b5. Violence against patients &/or visitors	Yes No Yes No Yes No Yes No Yes No
c. Recordkeeping process for tracking violent events	Yes No
d. Incident reporting, investigation, and evaluation methods	Yes No
e. Follow-up medical and psychological care	Yes No
f. Directions on how to access the facility’s post-incident response system	Yes No

Public reporting burden of this collection of information is estimated to average 60minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

3. Is a violence risk assessment completed? 01 Yes 02 No 03 Not stated

IF YES:

3a. How often are the assessments completed?

 At least annually  Other: _________________ 03 Not stated

3b. Which of the following job- or task-specific factors are included in the risk assessment?

Working with unstable or volatile persons	Yes No
Prevalence of weapons on site among patients, family, or visitors	Yes No
Presence of gang members	Yes No
Overcrowding and long waits for service that lead to client frustrations	Yes No
Isolated and/or solo work with patients and/or residents during examinations or treatment	Yes No
Lack of staff training	Yes No
Impact of staffing (including security personnel) as a factor that may increase the risk of violent events	Yes No

3c. Which of the following factors are examined when conducting walk through surveys for hazards in the physical environment?

Physical layout	Yes No
Unrestricted access points	Yes No
Crime rate in surrounding area	Yes No
Non-working alarm systems, communication devices, surveillance cameras and/or mirrors	Yes No
Poor lighting and visibility in facility	Yes No
Poor lighting and visibility in parking areas	Yes No

3d. Trends and patterns of violent events are examined through the collection and review of data? 01 Yes 02 No 03 Not stated

4. How often are the violence prevention policies, procedures and responsibilities updated?  Annually  Other: ___________________________ 03 Not stated

Additional Comments about Workplace Violence Prevention Program:

B. TRAINING

1. Do employees receive workplace violence prevention training?

01 Yes 02 No 03 Not stated

IF YES:

2. How frequently is the workplace violence prevention training offered?

 At hire  Quarterly  Yearly

 Other: __________________________ 03 Not stated

3. Length and recipients of workplace violence prevention training:

	New Hire	Recurring Training
a. How long is the workplace violence prevention training? (in minutes)
b. Which positions are included in the training?
Nurses	Yes Not Stated	Yes Not Stated
Physicians	Yes Not Stated	Yes Not Stated
Unlicensed support staff	Yes Not Stated	Yes Not Stated
Managers	Yes Not Stated	Yes Not Stated
Clerical staff	Yes Not Stated	Yes Not Stated
Security	Yes Not Stated	Yes Not Stated
Volunteers	Yes Not Stated	Yes Not Stated
Other: ___________________________________
c. Are contract employees included in the training?	Yes Not Stated	Yes Not Stated
d. Are per diem employees included in the training?	Yes Not Stated	Yes Not Stated
e. Are temporary staff included in the training?	Yes Not Stated	Yes Not Stated

4. Which formats are used for the training (check all that apply)?

 Lecture format (presentations)

 Reading prepared material/handouts in print

 Interactive discussions

 Role-playing

 DVD

 Computer-based training activities

 Other (Specify: _________________________________________________)

5. Who conducts the new hire training?

 Contract with a company that provides training to all new hires

(what company: ____________________________________________)

 Contract with a company that provides Train-the-Trainer sessions

(what company: _____________________________________________)

 Department in facility (which department: ____________________________)

 Not stated

6. Who conducts the recurring training?

 Contract with a company that provides training to all new hires

(what company: _____________________________________________)

 Contract with a company that provides Train-the-Trainer sessions

(what company: _____________________________________________)

 Department in facility (which department: ____________________________)

 Not stated

7. Which of the following components are included in the violence prevention training?

	New Hire Training	Recurring Training
a. Requirements of workplace violence administrative rules	Yes Not Stated	Yes Not Stated
b. Review of the facility’s relevant policies	Yes Not Stated	Yes Not Stated
c. Verbal methods to diffuse aggressive behavior	Yes Not Stated	Yes Not Stated
d. Physical maneuvers to diffuse or avoid aggressive behavior	Yes Not Stated	Yes Not Stated
e. Appropriate responses to workplace violence, including use of restraining techniques	Yes Not Stated	Yes Not Stated
f. Reporting requirements and procedures	Yes Not Stated	Yes Not Stated
g. Location and operation of safety devices	Yes Not Stated	Yes Not Stated
h. Resources for coping with violence	Yes Not Stated	Yes Not Stated
i. Summary and analysis of facility’s risk factors identified in the worksite analysis & preventive actions taken in response to the risk factors identified	Yes Not Stated	Yes Not Stated
j. Information on multicultural diversity to increase staff sensitivity to racial & ethnic issues & differences	Yes Not Stated	Yes Not Stated
k. Other violence-related topics (Specify: ______________________________________)

8. Does hospital staff receive specific training and demonstrations on the security equipment (e.g. alarms and cameras) and how to use it?

01 Yes 02 No 03 Not stated

9. How often is the training content reviewed?

 Annually  Other: __________________________________ 03 Not stated

Additional Comments about Workplace Violence Prevention Training:

C. RECORD KEEPING OF VIOLENT EVENTS AND INCIDENT INVESTIGATION

1. Does the facility keep records of all reported violent events?

01 Yes 02 No 03 Not stated

IF YES:

1a. Which department tracks the workplace violence reports?_____________________

1b. What type of data are recorded on the incident reports? (check all that apply)

 Incident date / time / location (circle all that apply)

 Job title of victim

 Activity at the time of the violent event

 Perpetrator

 Type of violent event

 Weapons used

 Description of any physical injuries

 Number of employees in the vicinity

 Employee actions in response to event

 Facility actions in response to event

 Recommendations

 Other (Specify: ____________________________________________

_________________________________________________________)

1c. Are reports tracked electronically?

01 Yes 02 No 03 Not stated

2. Are incident investigations conducted? 01 Yes 02 No 03 Not stated

IF YES:

2a. Who fills out the incident investigation reports? ________________________

2b. What is collected in the incident investigation reports? ____________________________________________________________________________________________________________________________________________

Additional Comments about Workplace Violence Reporting and Investigation:

D. POST-INCIDENT RESPONSE

1. What types of services are available for employees who have been injured during a violent event?

 Critical incident debriefing (by whom: ____________________________________)

 Employee health (medical care)  Psychological care/counseling

 Employee Assistance Programs  Other: ________________________

E. EQUIPMENT

1. What type(s) of equipment does the facility utilize?

a. Alarm Systems	Yes Not Stated
b. Cell phones	Yes Not Stated
c. Personal alarm devices	Yes Not Stated
d. Panic alarms	Yes Not Stated
e. Audio surveillance systems	Yes Not Stated
f. Video surveillance systems:	Yes Not Stated
g. Other:

2. Are appropriate personnel trained to respond to each alarm system in use?

01 Yes 02 No 03 Not stated

3. Are there trained security personnel posted in emergency departments, psychiatric wards, and in other locations, as needed?

01 Yes 02 No 03 Not stated

IF YES: Where are they posted? ________________________________________________

Additional Comments about Security Services:

H. VIOLENCE PREVENTION COMMITTEE

1. Does the facility have a violence prevention committee?

01 Yes 02 No 03 Not stated

IF YES:

1a. Which job titles serve on the committee? (Check all that apply.)

 Hospital Administrators  Risk Manager

 Security Director  Nurse Managers

 Staff Nurses  Staff Physicians

 Other (Specify: ____________________________________________)

1b. What percentage of the committee engages in direct patient contact? ____ 03 Not stated

1c. How often does the committee meet?

 Quarterly  Yearly  Other: ____________________

03 Not stated

1d. Is the violence prevention committee responsible for the following?

Completion of annual violence risk assessment	Yes No Not stated
Development of a written violence prevention plan	Yes No Not stated
Recommendations to the facility to reduce identified risks based on findings of the violence risk assessment	Yes No Not stated
Review of the design & layout of the facility as it relates to providing work areas safe from violence	Yes No Not stated
Development and maintenance of violence prevention training content and methods	Yes No Not stated
Development of strategies for encouraging the reporting of all incidents of workplace violence	Yes No Not stated
Development of procedures for reporting violent events	Yes No Not stated
Review data from post-incident reports in order to identify trends & make recommendations to prevent similar incidents	Yes No Not stated

Additional Comments about the Violence Prevention Committee: