Workplace Violence Incident Survey
 

The Workplace Violence Incident Survey is designed to collect information about physical, verbal, psychological, and sexual violence that occurs in health care settings. The individual completing the survey is asked to record the incident as accurately as possible. The respondent can record an incident that was experienced personally or an incident witnessed in the workplace.

Please fill out one survey for each workplace violence event. There is no limit on the number of workplace violence incidents that a respondent can report through this survey. All information is anonymous and will be collated through SurveyMonkey.

Thank you for your assistance in capturing information about workplace violence in health care settings.

1. Describe the type of violence that occured in the incident you are recording. (Check all that apply)
*For this survey, the term "staff" includes anyone who works in or comes to a health care setting to perform legitimate health care interventions (nurses, doctors, technicians, aides, etc)

2. Please indicate the individuals involved in the workplace violence incident.

3. Please indicate the setting and location where the workplace violence incident occurred. (Check all that apply)

4. Please indicate the amount of lost work as a result of the workplace violence incident.

5. What time frame did the workplace violence incident occur?

6. What month and year did the workplace violence incident occur?

7. How many people witnessed the incident? Indicate the numbers present in the classifications listed.

If no one else was present, enter 0 for each choice.

8. What was/were the outcome(s) for you after experiencing the workplace violence incident? (Check all that apply)

9. Elaborate or describe more fully your experience of workplace violence.

10. What can the Missouri Nurses Association (MONA) do to help prevent violence in the workplace?

11. If MONA pursues legislation on violence to health care workers, would you be willing to share your story at a legislative hearing at the Capitol?

If so, please provide your name, phone, and email.