Incident Information

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

10 7 2011 attachment-C3

Incident Information

OMB: 0920-0914

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Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx



Hospital Code: ____________ Incident ID: _______________


Workplace Violence Prevention Study



EMPLOYEE INCIDENT INFORMATION

Data Source: ____________________________________ Electronic Source: 01 Yes 02 No


1. Date of Incident: ___ / ___ / ___ 99 Unknown / Not specified

2. Time of Incident: ______ am / pm 99 Unknown / Not specified

3. Department Where Incident Occurred: __________________________ 99 Unknown / Not specified

4. Location of Incident: (check all that apply)

01 Admitting / Triage 05 Entrance / Exit / Restricted Entry 09 Seclusion / Time Out Room

02 Corridor Hallway/Stairwell 06 Lobby / Waiting Room 10 Dining Area

03 Day Room 07 Nurses Station 11 Outdoor Areas

04 Bathroom 08 Patient Room 99 Unknown / Not Specified

88 Other (Specify:____________________________________________________________________)

5. Victim occupation: ____________________________________ 99 Unknown / Not specified

(See NHSN Occupation Codes)

6. Activity at Time of Incident: (check all that apply)

01 Escorting 07 Combative / Defiant / Unruly (further unspecified)

02 Restraining 08 Elopement

03 Approaching / Redirecting 09 Unprovoked / Came up from behind

04 Assisting co-worker 10 Monitoring / Observing

05 Medical care / Nursing duties 99 Unknown / Not Specified

06 Responding to code / Intervening / Physically confronting / Taking down

88 Other (Specify:____________________________________________________________)

7. Perpetrator Relationship to Victim:

01 Criminal 03 Employee (Circle one: present / past ) 05 Patient Visitor

02 Patient 04 Domestic 99 Unknown / Not Specified

8. Number of Perpetrators: __________ 99 Unknown / Cannot be determined

9. Type of Violent Event: (check all that apply)

01 Physical Assault 03 Sexual Assault / Harassment

02 Verbal Assault / Threat 04 Unknown / Not Specified

88 Other (Specify: ____________________________________________________________)




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).






9. Weapon(s) Used: (check all that apply)

01 Fists / Hands / Nails 05 Floor / Door / Wall 09 Food / Utensils / Meal tray

02 Feet 06 Body (nonspecific) 11 Words / Verbal Threat 03 Gun / Knife 07 Furniture 99 Unknown / Not Specified

04 Teeth 08 Medical supply / Instrument

88 Other (Specify: ___________________________________________________________)





10. Type of Physical Injury: (check all that apply)

01 Abrasion / Cut / Laceration / Scratch 05 Dislocation / Fracture

02 Bite 06 Exposure to bodily fluids

03 Bruise / Contusion / Blunt Trauma 07 No Physical Injury

04 Sprain / Strain 99 Unknown / Not Specified

88 Other: (Specify: ___________________________________________________________)


11. Part of Body Injured: (check all that apply)

01 Head/Face/Neck 04 Back 07 Multiple body parts (not further specified)

02 Arm/Hand/Shoulder 05 Groin / Buttocks 08 No body part was physically hurt

03 Chest/Abdomen 06 Leg / Hip / Feet 99 Unknown / Not Specified

88 Other (Specify: ____________________________________________________________)

12. Was the employee unable to work for at least one full day after the incident?

01 Yes - Number of days: __________ 02 No 99 Unknown

13. Did the employee have restricted work duty?

01 Yes - Number of days: __________ 02 No 99 Unknown

14. Was medical attention provided? 01 Yes 02 No 99 Unknown

15. Number of employees in the vicinity when the incident occurred? __________ (For each employee, describe their actions in response to the incident, if any.)

a. ___________________________________________________________________________

b. ___________________________________________________________________________

c. ___________________________________________________________________________

d. ___________________________________________________________________________

e. ___________________________________________________________________________

f. ___________________________________________________________________________

16. Recommendations, if applicable, of police advisors, employees, or consultants.

Recommendation

Title of Person Making Recommendation

a.


b.


c.


d.


e.


f.


17. Actions taken by the facility in response to the incident.

a. ___________________________________________________________________________

b. ___________________________________________________________________________

c. ___________________________________________________________________________

d. ___________________________________________________________________________

e. ___________________________________________________________________________

f. ___________________________________________________________________________

18. Was law enforcement called? 01 Yes 02 No 99 Unknown


ADDITIONAL COMMENTS:



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