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Managing Violence and Aggression Against Staff
Managing Violence and Aggression Against Staff
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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
Please Select
Sexual
Physical Contact (Actual Assault)
Physical Contact / Threat (With a Weapon)
Physical Threat (No Contact)
Psychological
Verbal Abuse with Gender Content
Verbal Abuse with Disability Content
Verbal Abuse with Racial Content
Verbal Abuse General
Who has been Impacted
*
Please select
Staff
Agency Staff
Contractor
Other
Name
*
First
Last
Location Details
Location
*
Please select Location
CCGANI - Armagh
CCGANI - Derry/Londonderry
CCGANI - James House
CEC - Altnagelvin Hospital
CEC - Clady Villa Knockbracken
CEC - Craigavon Hospital
CEC - Fern House Antrim Area Hospital
CEC - Mahee
Clarendon Dock
County Hall
Franklin Street
Gransha Park House
Greenmount House - Ballymena
Great Victoria Street
ITS - James House
Leadership Centre
Lime Cabin
Linenhall Street
NIMDTA - Beechill House
NISCC - James House
PaLS - Altnagelvin Hospital
PaLS - Ards Hospital
PaLS - Belfast City Hospital
PaLS - Campsie 4b
PaLS - Campsie 4c
PaLS - Campsie 9d
PaLS - Gransha Park
PaLS - Boucher Crescent
PaLS - Carrickfergus - 1
PaLS - Carrickfergus - 7a
PaLS - Carrickfergus - 7b
PaLS - Downe Hospital
PaLS - Lissue
PaLS - Maple House - Antrim Area Hospital
PaLS - Royal Victoria Hospital
PaLS - SW Hospital
PaLS - The Cottage - Ballymena
PaLS - Ulster Hospital
PCC - Ballymena
PCC - James House
PCC - Lurgan
PCC - Omagh
Pinewood Villa - Armagh
Rosewood Villa - Armagh
RQIA - James House
RQIA - Omagh
Tower Hill
Tyrone & Fermanagh Hospital
Waterside House
Working From Home
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
*
Please select
Not Apparent
Abrasion
Amputation
Burn / Scald
Concussion
Dislocation
Fracture
Laceration
Loss
Pain
Sharps
Sprain / Strain
Other
Other - Please specify
*
Body Part(s)
*
Please specify which body part(s) have been impacted. (eg Left Leg etc.)
Degree of Harm (Severity)
*
Please select
Insignificant
Minor
Moderate
Major
Significant
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