Workplace Violence Report Form - Montefiore Medical Center
First Name
Last Name
Personal Email
Mobile Number
Facility/Campus
Please select...
Moses
Weiler
Home Health Agency
Westchester Square
Unit/work area
Were you directly involved in the incident?
Yes
I was a witness
I am aware it happened, but was not present when it occurred
Date of incident
Approximate time of incident
List the names of witnesses, including NYSNA, 1199, management, and other Montefiore staff:
Who was the perpetrator of the incident?
Patient
Visitor
Other
Other perpetrator type:
This incident included (select all that apply):
Verbal threats
Racist/sexist/homophobic verbal abuse
Physical threats
Physical assault
Assault with a weapon (knife, gun, hospital equipment, etc)
Bodily fluids (spitting, urine, feces, blood, etc)
Sexual harassment
Sexual assault
Other
Other incident type:
Was anyone on the unit physically injured? (select all that apply)
I was injured
My coworkers were injured
Patients/visitors were injured
Other
Other injured party:
Was security called or a code called? (select all that apply)
Yes, security office
Yes, called code
No
What was the approximate response time?
Please write a short paragraph about what occurred:
In response to this incident, I am requesting (select all that apply):
Paid time off (additional time, not from PTO)
Access to counseling services
Support in filing a police report
Follow up conversation with my manager
Follow up conversation with the security department
Other
Other response request:
Were the police contacted about the incident?
Yes
No
Did the police take your statement?
Yes
No
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