Table of Currently Approved and Requested Changes

OMB Approved	Changes
This question was not asked previously.	Are you currently working as a home healthcare aide in New Jersey?  Yes  No
1a. Do you receive violence-based safety training?  As a New Hire  Repeated  Both at New Hire and Repeated	1a.. Do you receive violence-based safety training?  As a New Hire  Refresher (e.g. annual)  Both at New Hire and Refresher
1b. How long is the violence-based safety training? New Hire: ______ (minutes) Repeated: ________ (minutes)	1b. How long is the violence-based safety training? New Hire: ______ (minutes) Refresher: ________ (minutes)
2. Do you consistently use your employer’s violence-based safety policies and procedures?  Always  Most of the Time  Rarely  Never	2. Do you consistently use your employer’s violence-based safety policies and procedures?  Always  Most of the Time  Rarely  Never  My employer does not have violence-based safety policies or procedures
Experienced Violent Events In the last year while at work, did you experience the following? Please refer to the currently approved chart on page 2.	Two new columns have been added to the current chart to include the following: “From patient or family member” and “From coworker or boss”. Please refer to the currently approved and requested versions on pages 2- 3.
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	This information is now being captured within a chart. Please refer to the currently approved and requested versions on page 4.
Age: ______years	Age:  19 or less  20-29  30-39  40-49  50-59  60 and over
Job Type (check all that apply):  Home Health Provider  Hospice Care Provider	Which employers do you work for?  Home Health Agency  Assisted Living Residence  Personal Care Home  Hospice  Contractor  Other___________  Independent Provider Which one of the above employers do you work for the most? _________
Employment Status (check one):  Full-time  Part-Time	Employment Status (check one): How many hours do you usually work in a week?  40 or more  30-39  20-29  <20
Experience: Length of time as a home health care provider: _______ years; _______month	Experience: Number of years as a home care provider: _______ years

Currently Approved

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

Requested Change

Experienced Violent Events

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

Type of Violence (For patient committing the violence, this is regardless of their state of being, such as dementia or substance use.)	From patient or family member	From coworker or boss
Verbal Assaults, With or Without a Weapon being yelled at, shouted at, or sworn at; threat of physical harm with or without a weapon; threat to damage or steal personal or workplace property	 Yes  No	 Yes  No
Physical Assaults an attack or attempted attack with or without a weapon (including hands/fists) with or without an injury	 Yes  No	 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	 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	 Yes  No
Vandalisms damage or destruction to personal (e.g. graffiti on worker’s car) or workplace (e.g. breaking medical supplies) property	 Yes  No	 Yes  No
Sexual Harassments/Assaults unwanted, offensive sexual behavior or comments (verbal or non-verbal); attacks of unwanted sexual contact, including rape, attempted rape, grabbing or fondling	 Yes  No	 Yes  No
Exposure to Bodily Fluids exposed on purpose to another person’s blood, saliva, urine, or any other bodily fluid	 Yes  No	 Yes  No
Bullying/Intimidation Less desirable assignments	 Yes  No	 Yes  No
Other types of violence. Please describe:

Currently Approved

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

Requested Change

Health Promotion

Does your home healthcare agency offer wellness classes for its employees, and if so, have you ever participated in a class?

Wellness class	Wellness classes offered by agency?	Participated in wellness classes offered by agency?
Stop Smoking	 Yes  No  Don’t Know	 Yes  No  N/A (not a smoker)
Diet and Nutrition	 Yes  No  Don’t Know	 Yes  No
Physical Activity	 Yes  No  Don’t Know	 Yes  No
Stress Management	 Yes  No  Don’t Know	 Yes  No