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

Are you currently working as a home healthcare aide in New Jersey?  Yes  No If Yes, please complete the survey and return it in the envelope provided.

If No, stop and return the survey in the envelope provided.

Violence-Based Safety Programs in Health Care

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

 Yes. Go to question 1a-e.

 No. Go to question 2.

 Unknown. Go to question 2.

IF YES:

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) Refresher: ____________ (minutes)

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

Review of the agency’s violence-based safety policies	 Yes  No  Unknown
Identification of predicting factors for violence	 Yes  No  Unknown
Verbal methods to stop aggressive behavior	 Yes  No  Unknown
Physical methods to stop 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
Requirements and procedures for reporting violence	 Yes  No  Unknown
Location and operation of safety devices	 Yes  No  Unknown
Resources for employee victims of violence	 Yes  No  Unknown
Other (please describe):

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).

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 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, 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:

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

Does your home healthcare agency offer exercise facilities for its employees?

 Yes  No  Don’t Know

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 commuting from your home to your agency’s work site and vice versa. (Check all that apply.)

 Yes- My vehicle was involved in an accident with another vehicle.

 Yes- Only my vehicle was involved (e.g., hit a tree).

 Yes- I was struck as a pedestrian by a motor vehicle (e.g., crossing the street to visit a patient.

 No

IF YES to any of the above: What was the result of the accident (check all that apply)?

 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.

Background

Age:  19 or less  20-29  30-39  40-49  50-59  60 and over

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

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 graduate work or advanced degree; (Field of study: ___________________)

Agency: Is your home healthcare agency part of a hospital?  Yes  No

Employment Status (check one):

How many hours do you usually work in a week?  40 or more  30-39  20-29  <20

Experience:

Number of years as a home care provider: _______ years

Which employers do you work for? (check all that apply)

 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? ______________________

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

5