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Managing Violence and Aggression Against Staff

Managing Violence and Aggression Against Staff

Home Managing Violence and Aggression Against Staff

Managing Violence and Aggression Against Staff

"*" indicates required fields

This form should be completed as close to an incident occurring as possible.

Person Impacted

Type of Violence / Aggression*

Please advise on what type of violence or aggression was received by the person concerned

Who has been Impacted*

Name*

First Last

Location Details

Location*

Department*

Additional Information*

Please specify floor / location etc.

Date of Incident*

DD slash MM slash YYYY

Time of Incident*

Hours

:

Minutes

Incident Details

Did Physical Harm Occur?*

Yes

No

Details of the Incident*

Please give a brief description of the incident in the Third Person only. Only state facts not opinions.

What Immediate Action(s) were taken?*

Notified Line Manager

First Aid

Ambulance Called

Referral to A&E

Security / Police

Occupational Health

Notified Relative

Other

Other Actions Taken - Please specify*

Detail of harm (injury) if apparent*

Other - Please specify*

Body Part(s)*

Please specify which body part(s) have been impacted. (eg Left Leg etc.)

Degree of Harm (Severity)*

Details of Treatment given or Hospitalisation*

Please upload any photographs of the incident

Max. file size: 20 MB.

Witness*

Please include Name, Department, and/or address and Contact number

Details of Person Reporting the Incident

Name*

First Last

Job Title*

HSCNI Email Address*

Telephone Number*

Line Manager's Name

First Last

Line Manager's HSCNI Email Address*

Also in this Section

Also in this Section

Managing Violence and Aggression Against Staff