Copy of Copy of CHCS Workplace Violence Survey

2.Survey questions taken from KHA Workplace Violence Survey

Confidentiality Statement: CHCS respects the privacy of our Associates.
Aggregate results of this survey may be used to support the establishment of education and training. We are requesting the name of the person completing this survey should staff wish to contact you for any follow-up questions. 
Survey Purpose: To collect information from CHCS Associates to determine the scope, frequency and severity of workplace violence and to determine what strategies are in place to address this growing issue. Using the survey data, CHCS plans to provide education and share best practices related to addressing violence in the health care setting.
1.Job Title - optional
2.Name - optional
3.Type of Facility (home location)(Required.)
DEFINITION OF WORKPLACE VIOLENCE:

An act or threat of violence involving a spoken or unspoken threat to personal safety, well being or health; and/or, other threatening disruptive behavior that occurs within health care facilities. The
term “workplace violence” shall not include lawful acts of self-defense or the defense of others.
Workplace violence includes, but is not limited to the following:

A. The threat or use of physical force, sexual assault, battery, harassment, bullying or intimidation, which may be verbal or non-verbal, against a caregiver or employee that results in, or has a high likelihood of resulting in injury, psychological trauma or stress, regardless of whether the employee sustains a physical injury;

B. An incident involving the threat or use of a firearm or other weapon, including the use of common objects as weapons, regardless of whether the employee sustains an injury.

C. An incident involving a patient, operating under an acute mental illness, significant cognitive impairment or an acute medical condition, who may be unable to understand the effects or the results of their actions. This type of incident is still considered a reportable event.

TYPES OF WORKPLACE VIOLENCE:
A. Violent acts by individuals who have no connection with the health care facility, but enter to obtain drugs, commit theft, or commit other criminal acts. 
B. Violence directed at employees, or other persons present, by customers, clients, patients, visitors, students, inmates, or any others for whom an organization provides services. (most common in health care)
C. Violence against coworkers, supervisors, managers, or others persons present by a current or former employee.
D. Violence committed in the health care facility by a non-employee, who may have a personal relationship with an employee, for example, a relative, spouse or domestic partner.
E. Violence not involving a health care worker, but occurring in a health care facility, or on its property. This may include patient/patient, visitor/patient, or visitor/visitor violence.
4.Within the past year, how often have you experienced or witnessed workplace violence committed by patients, visitors, students, inmates, or any others for whom CHCS provides services?(Required.)
5.Do you know how to report workplace violence?(Required.)
6.Are you concerned about workplace violence in your facility?
7.Within the last year, how often have you experienced or witnessed workplace violence in your department by another CHCS associate (current or former)?(Required.)
8.If your workplace has experienced a violent incident what types of events have occurred (Mark all that apply):(Required.)
9.During the last 12 months, have incidents of workplace violence increased or decreased, or stayed the same?(Required.)
10.Who has initiated violence in your workplace most often?(Required.)
11.Concerning workplace violence, do you think your department is:(Required.)
12.Where do most incidents of workplace violence occur at your facility?(Required.)
13.The frequency of workplace violence at your facility is the highest?(Required.)
14.What time do most incidents of workplace violence occur at your facility?(Required.)
15.Do you consider workplace violence to be part of the job?(Required.)
16.How would you rate the relationship between your facility and law enforcement?(Required.)
17.If you reported a workplace violence incident, in your opinion was the response provided in a timely manner?(Required.)
18.In your opinion what are the biggest barriers to reporting incidents of workplace violence? (mark all that apply)(Required.)
19.Thank you for taking this survey! If you have any further comment, please submit it here.
Current Progress,
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