Form 0920-0914 Employee Incident

Appendix H

Employee Incident Form

Form Approved

OMB No. 0920-0914

Exp. Date 01/31/2015

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 (0920-0914).

10. 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: ___________________________________________________________)

11. 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: ___________________________________________________________)

12. 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: ____________________________________________________________)

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

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

14. Did the employee have restricted work duty?

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

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

16. 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. ___________________________________________________________________________

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

Recommendation	Title of Person Making Recommendation
a.
b.
c.
d.
e.
f.

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

a. ___________________________________________________________________________

b. ___________________________________________________________________________

c. ___________________________________________________________________________

d. ___________________________________________________________________________

e. ___________________________________________________________________________

f. ___________________________________________________________________________

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

ADDITIONAL COMMENTS:

Form Approved

OMB No. 0920-0914

Exp. Date 01/31/2015

Nursing Home 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 (0920-0914).

10. 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: ___________________________________________________________)

11. 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: ___________________________________________________________)

12. 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: ____________________________________________________________)

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

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

14. Did the employee have restricted work duty?

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

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

16. 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. ___________________________________________________________________________

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

Recommendation	Title of Person Making Recommendation
a.
b.
c.
d.
e.
f.

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

a. ___________________________________________________________________________

b. ___________________________________________________________________________

c. ___________________________________________________________________________

d. ___________________________________________________________________________

e. ___________________________________________________________________________

f. ___________________________________________________________________________

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

ADDITIONAL COMMENTS: