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.

Question Title

* 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)

verbal threat/intimidating action to self

verbal threat/intimidating action to other staff

verbal threat/intimidating action to patient

verbal threat/intimidating action to family members

verbal threat/intimidating action to visitor (no relationship to patient)

physical violence to self

physical violence to other staff

physical violence to patient

physical violence to family member

physical violence to visitor (no relationship to patient)

sexual harassment

inappropriate touching

written/electronic threats

Question Title

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

patient to employee

patient to patient

patient to visitor

employee to patient

employee to employee

employee to visitor

visitor to employee

visitor to patient

physician to nurse

other (please specify)

Question Title

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

SETTING:

office-based practice/clinic

hospital/acute care facility

long-term care facility

COMMUNITY-BASED HEALTH CARE:

patient home

school

senior citizen center

other (please specify below)

LOCATION:

exam/procedure room

patient room

meeting/staffing room

nursing station

stairwell/elevator

bathroom/lounge

parking lot/parking garage

transport vehicle (ambulance, etc)

room in patient's house

other (please specify)

Question Title

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

no work absence

one absence

less than one week

more than one week

continue to experience residual lost time

other (please specify)

Question Title

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

morning (6 am to noon)

afternoon (noon to 6 pm)

evening (6 pm to 11 pm)

night (11 pm to 6 am)

Question Title

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

Month (MM)

Year (YYYY)

Question Title

* 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.

supervisor

LPN

support staff

other health care providers (PT, lab, etc)

physician

office personel

patient

visitors

Question Title

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

sought medical care

sought psychological care

experienced emotional responses (anger, sadness, denial)

blamed self

experienced decreased productivity (distracted)

increased absenteeism

notified law enforcement (if so, note how soon after incident in "other" box below)

resigned position

changed position

patients were endangered (because of fear of contacting physician at night)

other (please specify)

Question Title

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

Question Title

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

conference

workshop

online continuing education

series of articles

other (please specify)

Question Title

* 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.

Question Title

* 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)

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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.

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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.

* 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)

* 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.

* 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.