Workplace Violence Incident Survey
ONA is gathering data on workplace violence incidents in order to reach our goal of preventing violence against nurses in the workplace. Information in this survey is confidential and will only be used for the purpose of collecting data on the prevalence of violence in the workplace. A violent incident is defined as any verbal threat and/or physical assault occuring to a worker while on duty, including verbal harrassment, threats, intimidations, racial slurs, stalking, sabotaging another's work, destroying/stealing company's or another co-worker's property, threatening letters, email, voicemail, unwanted sexual advances, overt and covert behaviors, physical assault, rape, domestic violence and homicide. Please use the below survey to provide information about any incidences of workplace violence you have experienced.
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1
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During my nursing career, I have experienced or observed workplace violence:
| Within the past month |
| Within the past 6 months |
| Within the past year |
| Over a year ago |
| Never |
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2
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Please select from the below options the type(s) of workplace violence that best describes what you experienced or observed:
| Destruction of property |
| Stalking |
| Verbal Assault |
| Threats (verbal or via phone, email) |
| Rape |
| Sexual Assault |
| Having your work sabotaged |
| Unwanted sexual advances |
| Domestic Violence |
| Physical Assault |
| Racial Slurs |
| Other, please specify |
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3
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Did the perpetrator have a weapon?
| Yes |
| No |
| I don't know |
| If yes, what kind of weapon? |
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4
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| Yes |
| No |
| I don't know |
| If yes, please describe the injuries: |
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5
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| Monday |
| Tuesday |
| Wednesday |
| Thursday |
| Friday |
| Saturday |
| Sunday |
| I Don't Know |
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6
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| Early morning |
| Morning |
| Afternoon |
| Evening |
| Late Evening |
| Other, please specify |
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7
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Where did the incident occur?
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8
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Was the perpetrator of the violence male or female?
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9
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The victim(s) of the violence was a:
| Patient |
| Physician |
| Other Staff Person |
| Nurse |
| Visitor |
| Other, please specify |
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10
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The perpetrator of the violence was a:
| Patient |
| Physician |
| Visitor |
| Nurse |
| Other Staff Person |
| Other, please specify |
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11
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Please check any of the following predisposing factors:
| I don't know |
| Prior history of violence |
| Intoxication |
| Gang Related |
| Dissatisfied with care |
| None that I observed |
| Grief reaction |
| Dissatisfied with waiting time |
| Other, please specify |
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12
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Did the person leave the area because of the incident?
| Yes |
| No |
| I don't know |
| Other, please specify |
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13
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Please check any of the below that were present during the incident:
| Police |
| Hospital Security |
| Other, please specify |
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14
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Please check who was called due to the incident:
| Police |
| Hospital Security |
| Other, please specify |
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15
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How was the incident terminated?
| Incident diffused by victim |
| Incident diffused by other hospital staff |
| Incident diffused by hospital security |
| Arrival of Police Officers |
| Perpetrator Arrested |
| Other, please specify |
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16
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What did the perpetrator do after the incident?
| Stayed on premises |
| Escorted off premises |
| Left on own |
| Other, please specify |
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17
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Does your employer have a policy or mechanism in place for reporting workplace violence?
| Yes |
| No |
| I Don't Know |
| Other, please specify |
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18
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Was the incident reported to the employer?
| Yes |
| No |
| I Don't Know |
| If no, why not? |
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19
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Please describe the incident in your own words, and provide any additional information you wish to provide.
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