Metro Health Safety and Security

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information

• Name of Person Committing the Act of Violence

• Classify Subject

  Select Employee Patient Visitor Contractor Vendor Volunteer

  • Employee
  • Patient
  • Visitor
  • Contractor
  • Vendor
  • Volunteer

• Gender of Assailant

  Male

  Female

• Was the Assailant Armed With a Weapon?

  Yes

  No

  N/A

• Violence Directed Towards:

  Employee

  Patient

  Visitor

• Predisposing Factors of Assail

  Intoxication

  Dissatisfied with care/wait time

  Grief reaction

  Prior history of violence

  Gang related

• Other

Description of Incident

• Date and Time of Incident

  Date

• Location of Incident

• Physical abuse?

  Yes

  No

  N/A

• Injuries?

  Yes

  No

  N/A

• Extent of injuries:

• Verbal abuse?

  Yes

  No

  N/A

• Describe if other type of abuse:

• Detailed description of incident

• Did anyone leave the area due to the incident?

  Yes

  No

  N/A

Assistance

• Was Security requested?

  Yes

  No

  N/A

• Did Security respond in a timely fashion?

  Yes

  No

  N/A

• Did the Police Dept respond to assist?

  Yes

  No

  N/A

Termination of Incident

• Incident diffused?

  Yes

  No

  N/A

• Police notified?

  Yes

  No

  N/A

• Assailant arrested?

  Yes

  No

  N/A

• Disposition of Assailant

  Stayed on premises

  Escorted of premises

  Left on own

• Restraints used?

  Yes

  No

  N/A

• Was Risk notified?

  Yes

  No

  N/A

• Person completing report signature

  Sign

• Type name and title of person completing report

• Select date

  Date