Home Healthcare Aides Survey

Appendix C5:

Healthcare Facility Workplace Violence Prevention Programs Home Healthcare Aide Survey

Form Approved

OMB No. 0920-0914

Exp. Date 01/31/2015

HEALTHCARE FACILITY WORKPLACE VIOLENCE PREVENTION PROGRAMS

Home Healthcare Aide Survey

BACKGROUND

Age: ______ years

Sex:  Male  Female

Race / Ethnicity (check all that apply):

• White or Caucasian

• Black or African American

• Asian

• Native Hawaiian / Pacific Islander

• Native American Indian or Alaskan

• Hispanic / Latino

• Other (Specify: ____________________)

Education (check highest level completed):

• Less than High School Diploma

• High School Diploma / GED

• Some college, including Associate Degree

• Bachelor’s Degree (Field of study: ___________________________)

• Some post-graduate work or advanced degree; (Field of study: ___________________)

Job Type (check all that apply):  Home Health Provider  Hospice Care Provider

Employment Status (check one):  Full-time  Part-time

Experience:

Length of time as a home health care provider: _______ years; _______ month

Contract or Registry Employee (check one):  Yes  No

Case Load:

What is the average number of home visits you make per month? _______ number per month

Safety at Work:

On a scale from 1-10 with “1” being never feel safe and “10” being always feel safe, how safe do you generally feel when making home visits? (Please circle one number)

1 2 3 4 5 6 7 8 9 10

Never feel safe Always feel safe

Public reporting burden of this collection of information is estimated to average 20 minutes 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 (0920-0914).

Is your home healthcare agency associated with a hospital?  Yes  No

Health Promotion

Does your home healthcare agency offer wellness classes for its employees?

Smoking Cessation  Yes  No

Diet and Nutrition  Yes  No

Physical Activity  Yes  No

Stress Management  Yes  No

Does your home healthcare agency offer exercise facilities for its employees?  Yes  No

Driving

Has your employer ever given you any information about safe driving on the job? This may include training, safety talks, videos, or information about traffic laws or company policies.

 Yes

 No

 Don’t know

In the past 12 months, have you been involved in a motor vehicle accident while on the job?

Please include only accidents that took place during your work day (for example, while driving to visit a patient or crossing the street to attend a work meeting). Do not include accidents that took place while you were driving to or from work.

Yes

 No

 Don’t know

If YES:

What type of accident was it?

 My vehicle was involved in a collision with another vehicle.

 My vehicle was involved in a single-vehicle accident.

 I was struck by a motor vehicle.

What was the result of the accident?

 There was no damage to any vehicle involved, and no injuries.

 There was damage to one or more vehicles or to nearby property, but no one was injured.

 I was injured, but I did not need medical treatment.

 I was injured severely enough to need medical treatment or to miss work for more than 4 hours.

Experienced Violent Events

In the last year while at work, did you experience the following?

Type of Violence		Experienced at work in last year
	Verbal Assaults being yelled at, shouted at, or sworn at	Yes No
	Verbal Threats Without a Weapon threat of physical harm without a weapon; threat to damage or steal personal or workplace property	Yes No
	Verbal Threats With a Weapon threat of physical harm with a weapon; threat to damage or steal personal or workplace property	Yes No
	Physical Assaults an attack or attempted attack with or without a weapon (including hands/fists) resulting in no injury or injury at any severity level	Yes No
	Robberies & Muggings taking or attempting to take personal (e.g. purse) or workplace (e.g., medicine, medical supplies) property by force or threat of force	Yes No
	Property Thefts taking of personal or workplace property without personal threat, attack, or bodily harm (e.g. stealing medical supplies out of worker’s car)	Yes No
	Vandalisms damage or destruction to personal (e.g. graffiti on worker’s car) or workplace property (e.g. breaking medical supplies)	Yes No
	Sexual Harassments Unwanted, offensive sexual behavior or comments (verbal or non-verbal)	Yes No
	Sexual Assaults Attacks of unwanted sexual contact, including rape, attempted rape, grabbing or fondling	Yes No
	Exposure to Bodily Fluids Exposed on purpose to another person’s blood saliva, urine, or any other bodily fluid	Yes No

VIOLENCE-BASED SAFETY PROGRAMS IN HEALTH CARE

1. Did you receive training about violence-based safety in your workplace?

 Yes- Please answer questions 1a-1e

 No- Please continue to question 2

 Unknown- Please continue to question 2

IF YES:

1a. Do you receive violence-based safety training:

 As a New Hire  Repeated  Both at New Hire and Repeated

1b. How long is the violence-based safety training?

New Hire: ____________ (minutes) Repeated: ____________ (minutes)

1c. Which of the following components are included in the violence-based safety training either at new hire or on a repeated basis?

Review of the facility’s violence-based safety policies	Yes No Unknown
Identification of predicting factors for aggression and violence	Yes No Unknown
Verbal methods to diffuse aggressive behavior	Yes No Unknown
Physical methods to diffuse or avoid aggressive behavior	Yes No Unknown
Obtaining a history on a patient with violent behavior	Yes No Unknown
Techniques for restraining violent patients	Yes No Unknown
Self-defense if preventive action does not work	Yes No Unknown
Appropriate use of medications to subdue aggressive patients	Yes No Unknown
Requirements and procedures for reporting a violent event	Yes No Unknown
Location and operation of safety devices	Yes No Unknown
Resources for employee victims of violence	Yes No Unknown
Worksite-specific summary of risk factors for violence and preventive actions taken in response	Yes No Unknown
Information on multicultural diversity to increase sensitivity to racial and ethnic issues and differences	Yes No Unknown

1d. What, if anything, do you feel should be changed about the training? ________________________________________________________________________________

1e. How good would you say your violence-based safety training program is:

 Excellent  Very Good  Adequate  Not very good

2. Do you consistently employ your facility’s violence-based safety policies and procedures?

 Always  Most of the Time  Rarely  Never

____________________________________________________________________________

3. Have you heard about the New Jersey Violence Prevention in Health Care Facilities Act?

 Yes- If Yes, how did you hear about it?

 No

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