1

Guidelines for Preventing Workplace

Violence for Health-Care and

Social-Service Workers

OSHA 3148

2003 (Revised)
2

This informational booklet provides a

generic, non-exhaustive overview of a

particular topic related to OSHA standards.

It does not alter or determine compliance

responsibilities in OSHA standards or the

Occupational Safety and Health Act of 1970.

Because interpretations and enforcement

policy may change over time, you should

consult current administrative interpretations

and decisions by the Occupational Safety and

Health Review Commission and the Courts

for additional guidance on OSHA compliance

requirements.

This publication is in the public domain

and may be reproduced, fully or partially,

without permission. Source credit is requested

but not required.

This information is available to sensory

impaired individuals upon request. Voice

phone: (202) 693–1999; teletypewriter

(TTY) number: (877) 889–5627.
i

Guidelines for Preventing Workplace

Violence for Health-Care and

Social-Service Workers

U.S. Department of Labor

Elaine L. Chao, Secretary

Occupational Safety and Health Administration

John L. Henshaw, Assistant Secretary

OSHA 3148

2003 (Revised)
iii

Contents

Notice ...................................................................... v

Acknowledgments .............................................. vi

Introduction ........................................................... 1

Overview of Guidelines ...................................... 3

Violence Prevention Programs .......................... 4

Management commitment and employee involvement................. 5

Worksite analysis .......................................................................... 5

Hazard prevention and control .................................................... 7

Safety and health training........................................................... 10

Recordkeeping and program evaluation .................................... 12

Conclusion............................................................ 14

References ............................................................ 15

Appendices

A: Workplace Violence Program Checklists............................... 17

B: Violence Incident Report Forms............................................. 22

C: Suggested Readings ............................................................... 24

D: OSHA Assistance, Services, and Programs ........................... 26

E: OSHA Regional Office Directory ......................................... 29
v

Notice

Duty Clause,”2 for enforcement authority.

Failure to implement these guidelines is not

in itself a violation of the General Duty

Clause. However, employers can be cited for

violating the General Duty Clause if there is

a recognized hazard of workplace violence

in their establishments and they do nothing

to prevent or abate it.

When Congress passed the OSH Act,

it recognized that workers’ compensation

systems provided state-specific remedies for

job-related injuries and illnesses. Determining

what constitutes a compensable claim and the

rate of compensation were left to the states,

their legislatures, and their courts. Congress

acknowledged this point in Section 4(b)(4)

of the OSH Act, when it stated categorically:

“Nothing in this chapter shall be construed

to supersede or in any manner affect any

workmen’s compensation law. . ..”3 Therefore,

these non-mandatory guidelines should not be

viewed as enlarging or diminishing the scope

of work-related injuries. The guidelines are

intended for use in any state and without

regard to whether any injuries or fatalities

are later determined to be compensable.

These guidelines are not a new standard

or regulation. They are advisory in nature,

informational in content, and intended to

help employers establish effective workplace

violence prevention programs adapted to

their specific worksites. The guidelines do

not address issues related to patient care.

They are performance-oriented, and how

employers implement them will vary based

on the site’s hazard analysis.

Violence inflicted on employees may come

from many sources—external parties such as

robbers or muggers and internal parties such

as coworkers and patients. These guidelines

address only the violence inflicted by patients

or clients against staff. However, OSHA

suggests that workplace violence policies

indicate a zero-tolerance for all forms of

violence from all sources.

The Occupational Safety and Health Act

of 1970 (OSH Act)1 mandates that, in addition

to compliance with hazard-specific standards,

all employers have a general duty to provide

their employees with a workplace free from

recognized hazards likely to cause death or

serious physical harm. OSHA will rely on

Section 5(a)(1) of the OSH Act, the “General

1 Public Law 91-596, December 29, 1970;

and as amended by P.L. 101-552, Section 3101,

November 5, 1990.

2 “Each employer shall furnish to each of his

employees employment and a place of employment

which are free from recognized hazards that are

causing or are likely to cause death or serious

physical harm to his employees.”

3 29 U.S.C. 653(b)(4).
vi

Acknowledgments

Many people have contributed to these guidelines. They include

health-care, social-service, and employee-assistance experts;

researchers; educators; unions and other stakeholders; OSHA

professionals; and the National Institute for Occupational Safety

and Health (NIOSH).

Also, several states have developed relevant standards or

recommendations, such as California OSHA’s CAL/OSHA

Guidelines for Workplace Security and Guidelines for Security

and Safety of Health Care and Community Service Workers;

New Jersey Public Employees Occupational Safety and Health’s

Guidelines on Measures and Safeguards in Dealing with Violent

or Aggressive Behavior in Public Sector Health Care Facilities;

and the State of Washington Department of Labor and Industries’

Violence in Washington Workplaces, and Study of Assaults on Staff

in Washington State Psychiatric Hospitals. Other organizations

with relevant recommendations include the Joint Commission

on Accreditation of Health Care Organizations’ Comprehensive

Accreditation Manuals for Hospitals, the Metropolitan Chicago

Healthcare Council’s Guidelines for Dealing with Violence in

Health Care, and the American Nurses Association’s Promoting

Safe Work Environments for Nurses. These and other agencies

have information available to assist employers.
1

Introduction

occupational assaults and violent acts occurred

in health care and social services. Most of these

occurred in hospitals, nursing and personal-care

facilities, and residential-care services. Nurses,

aides, orderlies, and attendants suffered the

most non-fatal assaults resulting in injury.

Injury rates also reveal that health-care

and social-service workers are at high risk of

violent assault at work. BLS rates measure the

number of events per 10,000 full-time workers

—in this case, assaults resulting in injury.

In 2000, health-service workers overall had

an incidence rate of 9.3 for injuries resulting

from assaults and violent acts. The rate for

social-service workers was 15, and for nursing

and personal-care facility workers, 25.

This compares to an overall private sector

injury rate of 2.

The Department of Justice’s (DOJ) National

Crime Victimization Survey for 1993 to 1999

lists average annual rates of non-fatal violent

What is workplace violence and

how does it affect health-care

and social-service workers?

The National Institute for Occupational

Safety and Health (NIOSH) defines workplace

violence as “violent acts (including physical

assaults and threats of assaults) directed toward

persons at work or on duty.”4 This includes

terrorism as illustrated by the terrorist acts of

September 11, 2001 that resulted in the deaths

of 2,886 workers in New York, Virginia, and

Pennsylvania. Although these guidelines do

not address terrorism specifically, this type of

violence remains a threat to U.S. workplaces.

For many years, health-care and socialservice workers have faced a significant risk

of job-related violence. Assaults represent a

serious safety and health hazard within these

industries. OSHA’s violence prevention guidelines

provide the agency’s recommendations for

reducing workplace violence, developed

following a careful review of workplace

violence studies, public and private violence

prevention programs, and input from

stakeholders. OSHA encourages employers to

establish violence prevention programs and to

track their progress in reducing work-related

assaults. Although not every incident can be

prevented, many can, and the severity of

injuries sustained by employees can be reduced.

Adopting practical measures such as those

outlined here can significantly reduce this

serious threat to worker safety.

How extensive is the problem?

The Bureau of Labor Statistics (BLS) reports

that there were 69 homicides in the health

services from 1996 to 2000. Although workplace

homicides may attract more attention, the vast

majority of workplace violence consists of

non-fatal assaults. BLS data shows that in

2000, 48 percent of all non-fatal injuries from

4CDC/NIOSH. Violence. Occupational Hazards

in Hospitals. 2002.

30

25

20

15

10

5

0

Incidence rates for nonfatal assaults

and violent acts by industry, 2000

Incidence rate per 10,000 full-time workers

Nursing and

Personal

Care

Facilities

Social

Services

Health

Services

Overall

Private

Sector

Overall
2

crime by occupation. The average annual rate

for non-fatal violent crime for all occupations

is 12.6 per 1,000 workers. The average annual

rate for physicians is 16.2; for nurses, 21.9;

for mental health professionals, 68.2; and

for mental-health custodial workers, 69.

(Note: These data do not compare directly to

the BLS figures because DOJ presents violent

incidents per 1,000 workers and BLS displays

injuries involving days away from work per

10,000 workers. Both sources, however, reveal

the same high risk for health-care and socialservice workers.)

As significant as these numbers are, the

actual number of incidents is probably much

higher. Incidents of violence are likely to be

underreported, perhaps in part due to the

persistent perception within the health-care

industry that assaults are part of the job.

Underreporting may reflect a lack of

institutional reporting policies, employee

beliefs that reporting will not benefit them,

or employee fears that employers may deem

assaults the result of employee negligence or

poor job performance.

What are the risk factors?

Health-care and social-service workers face

an increased risk of work-related assaults

stemming from several factors. These include:

■ The prevalence of handguns and other

weapons among patients, their families,

or friends;

■ The increasing use of hospitals by police and

the criminal justice system for criminal holds

and the care of acutely disturbed, violent

individuals;

■ The increasing number of acute and

chronic mentally ill patients being released

from hospitals without follow-up care

(these patients have the right to refuse

medicine and can no longer be hospitalized

involuntarily unless they pose an immediate

threat to themselves or others);

■ The availability of drugs or money at

hospitals, clinics, and pharmacies, making

them likely robbery targets;

■ Factors such as the unrestricted movement

of the public in clinics and hospitals and long

waits in emergency or clinic areas that lead

to client frustration over an inability to

obtain needed services promptly;

■ The increasing presence of gang members,

drug or alcohol abusers, trauma patients,

or distraught family members;

■ Low staffing levels during times of increased

activity such as mealtimes, visiting times,

and when staff are transporting patients;

■ Isolated work with clients during

examinations or treatment;

■ Solo work, often in remote locations with

no backup or way to get assistance, such as

communication devices or alarm systems

(this is particularly true in high-crime

settings);

■ Lack of staff training in recognizing and

managing escalating hostile and assaultive

behavior; and

■ Poorly lit parking areas.
3

Overview of Guidelines

The guidelines cover a broad spectrum

of workers who provide health care and

social services in psychiatric facilities, hospital

emergency departments, community mental

health clinics, drug abuse treatment clinics,

pharmacies, community-care facilities,

and long-term-care facilities. They include

physicians, registered nurses, pharmacists,

nurse practitioners, physicians’ assistants,

nurses’ aides, therapists, technicians, public

health nurses, home health-care workers,

social workers, welfare workers, and

emergency medical care personnel. The

guidelines may also be useful in reducing risks

for ancillary personnel such as maintenance,

dietary, clerical, and security staff in the

health-care and social-service industries.

5OSHA’s Safety and Health Program Management

Guidelines (Federal Register 54 (16):3904–3916,

January 26, 1989).

In January 1989, OSHA published

voluntary, generic safety and health program

management guidelines for all employers to

use as a foundation for their safety and health

programs, which can include workplace

violence prevention programs.5 OSHA’s

violence prevention guidelines build on these

generic guidelines by identifying common risk

factors and describing some feasible solutions.

Although not exhaustive, the workplace

violence guidelines include policy

recommendations and practical corrective

methods to help prevent and mitigate the

effects of workplace violence.

The goal is to eliminate or reduce worker

exposure to conditions that lead to death or

injury from violence by implementing effective

security devices and administrative work

practices, among other control measures.
4

Violence Prevention Programs

representatives and others who can help

identify ways to prevent and mitigate

workplace violence.

■ Assign responsibility and authority for

the program to individuals or teams with

appropriate training and skills. Ensure that

adequate resources are available for this

effort and that the team or responsible

individuals develop expertise on workplace

violence prevention in health care and

social services.

■ Affirm management commitment to a

worker-supportive environment that places

as much importance on employee safety and

health as on serving the patient or client.

■ Set up a company briefing as part of the

initial effort to address issues such as

preserving safety, supporting affected

employees, and facilitating recovery.

What are the elements of an effective

violence prevention program?

The five main components of any effective

safety and health program also apply to the

prevention of workplace violence:

■ Management commitment and employee

involvement;

■ Worksite analysis;

■ Hazard prevention and control;

■ Safety and health training; and

■ Recordkeeping and program evaluation.

What should a violence

prevention program include?

A written program for job safety and

security, incorporated into the organization’s

overall safety and health program, offers an

effective approach for larger organizations.

In smaller establishments, the program does

not need to be written or heavily documented

to be satisfactory.

What is needed are clear goals and objectives

to prevent workplace violence suitable for the

size and complexity of the workplace operation

and adaptable to specific situations in each

establishment. Employers should communicate

information about the prevention program and

startup date to all employees.

At a minimum, workplace violence prevention

programs should:

■ Create and disseminate a clear policy of zero

tolerance for workplace violence, verbal and

nonverbal threats, and related actions. Ensure

that managers, supervisors, coworkers, clients,

patients, and visitors know about this policy.

■ Ensure that no employee who reports or

experiences workplace violence faces

reprisals.6

■ Encourage employees to promptly report

incidents and suggest ways to reduce or

eliminate risks. Require records of incidents

to assess risk and measure progress.

■ Outline a comprehensive plan for maintaining

security in the workplace. This includes

establishing a liaison with law enforcement

6 Section 11 (c)(1) of the OSH Act applies to

protected activity involving the hazard of workplace

violence as it does for other health and safety matters:

“No person shall discharge or in any manner

discriminate against any employee because such

employee has filed any complaint or instituted or

caused to be instituted any proceeding under or

related to this Act or has testified or is about to

testify in any such proceeding or because of the

exercise by such employee on behalf of himself or

others of any right afforded by this Act.”
5

Management Commitment

and Employee Involvement

What role do management commitment

and employee involvement play?

Management commitment and employee

involvement are complementary and essential

elements of an effective safety and health

program. To ensure an effective program,

management and front-line employees must

work together, perhaps through a team or

committee approach. If employers opt for this

strategy, they must be careful to comply with

the applicable provisions of the National Labor

Relations Act.7

Management commitment, including the

endorsement and visible involvement of top

management, provides the motivation and

resources to deal effectively with workplace

violence. This commitment should include:

■ Demonstrating organizational concern for

employee emotional and physical safety

and health;

■ Exhibiting equal commitment to the safety

and health of workers and patients/clients;

■ Assigning responsibility for the various

aspects of the workplace violence prevention

program to ensure that all managers,

supervisors, and employees understand

their obligations;

■ Allocating appropriate authority and

resources to all responsible parties;

■ Maintaining a system of accountability

for involved managers, supervisors, and

employees;

■ Establishing a comprehensive program of

medical and psychological counseling and

debriefing for employees experiencing or

witnessing assaults and other violent

incidents; and

■ Supporting and implementing appropriate

recommendations from safety and health

committees.

Employee involvement and feedback enable

workers to develop and express their own

commitment to safety and health and provide

useful information to design, implement, and

evaluate the program.

Employee involvement should include:

■ Understanding and complying with the

workplace violence prevention program

and other safety and security measures;

■ Participating in employee complaint or

suggestion procedures covering safety and

security concerns;

■ Reporting violent incidents promptly and

accurately;

■ Participating in safety and health committees

or teams that receive reports of violent

incidents or security problems, make

facility inspections, and respond with

recommendations for corrective strategies;

and

■ Taking part in a continuing education

program that covers techniques to recognize

escalating agitation, assaultive behavior, or

criminal intent and discusses appropriate

responses.

Worksite Analysis

What is a worksite analysis, and

what is its value?

A worksite analysis involves a step-by-step,

common-sense look at the workplace to find

existing or potential hazards for workplace

violence. This entails reviewing specific

procedures or operations that contribute to

hazards and specific areas where hazards may

develop. A threat assessment team, patient

assault team, similar task force, or coordinator

may assess the vulnerability to workplace 7 Title 29 U.S.C., Section 158(a)(2).
6

violence and determine the appropriate

preventive actions to be taken. This group

may also be responsible for implementing

the workplace violence prevention program.

The team should include representatives from

senior management, operations, employee

assistance, security, and occupational safety

and health, legal, and human resources staff.

The team or coordinator can review injury

and illness records and workers’ compensation

claims to identify patterns of assaults that

could be prevented by workplace adaptation,

procedural changes, or employee training. As

the team or coordinator identifies appropriate

controls, they should be instituted.

What does a worksite analysis include?

The recommended program for worksite

analysis includes, but is not limited to:

■ Analyzing and tracking records;

■ Screening surveys; and

■ Analyzing workplace security.

What does records analysis and

tracking involve?

This activity should include reviewing

medical, safety, workers’ compensation, and

insurance records—including the OSHA Log of

Work-Related Injury and Illness (OSHA 300),

if the employer is required to maintain one—

to pinpoint instances of workplace violence.

Scan unit logs and employee and police reports

of incidents or near-incidents of assaultive

behavior to identify and analyze trends in

assaults relative to particular:

■ Departments;

■ Units;

■ Job titles;

■ Unit activities;

■ Work stations; and

■ Time of day.

Tabulate these data to target the frequency

and severity of incidents to establish a baseline

for measuring improvement. Monitor trends

and analyze incidents. Contacting similar local

businesses, trade associations, and community

and civic groups is one way to learn about their

experiences with workplace violence and to

help identify trends. Use several years of data,

if possible, to trace trends of injuries and

incidents of actual or potential workplace

violence.

What is the value of screening surveys?

One important screening tool is an employee

questionnaire or survey to get employees’ ideas

on the potential for violent incidents and to

identify or confirm the need for improved

security measures. Detailed baseline screening

surveys can help pinpoint tasks that put

employees at risk. Periodic surveys—conducted

at least annually or whenever operations

change or incidents of workplace violence

occur—help identify new or previously

unnoticed risk factors and deficiencies or

failures in work practices, procedures, or

controls. Also, the surveys help assess the

effects of changes in the work processes.

The periodic review process should also

include feedback and follow-up.

Independent reviewers, such as safety

and health professionals, law enforcement or

security specialists, and insurance safety

auditors, may offer advice to strengthen

programs. These experts can also provide fresh

perspectives to improve a violence prevention

program.

How do you conduct a workplace

security analysis?

The team or coordinator should periodically

inspect the workplace and evaluate employee

tasks to identify hazards, conditions,

operations, and situations that could lead

to violence.
7

To find areas requiring further evaluation,

the team or coordinator should:

■ Analyze incidents, including the characteristics

of assailants and victims, an account of what

happened before and during the incident,

and the relevant details of the situation and

its outcome. When possible, obtain police

reports and recommendations.

■ Identify jobs or locations with the greatest

risk of violence as well as processes and

procedures that put employees at risk of

assault, including how often and when.

■ Note high-risk factors such as types of

clients or patients (for example, those with

psychiatric conditions or who are disoriented

by drugs, alcohol, or stress); physical risk

factors related to building layout or design;

isolated locations and job activities; lighting

problems; lack of phones and other

communication devices; areas of easy,

unsecured access; and areas with previous

security problems.

■ Evaluate the effectiveness of existing security

measures, including engineering controls.

Determine if risk factors have been reduced

or eliminated and take appropriate action.

Hazard Prevention and Control

After hazards are identified through the

systematic worksite analysis, the next step is

to design measures through engineering or

administrative and work practices to prevent

or control these hazards. If violence does occur,

post-incident response can be an important tool

in preventing future incidents.

What engineering controls and workplace

adaptations can minimize risk?

Engineering controls remove the hazard

from the workplace or create a barrier between

the worker and the hazard. There are several

measures that can effectively prevent or control

workplace hazards, such as those described in

the following paragraphs. The selection of any

measure, of course, should be based on the

hazards identified in the workplace security

analysis of each facility. Among other options,

employers may choose to:

■ Assess any plans for new construction or

physical changes to the facility or workplace

to eliminate or reduce security hazards.

■ Install and regularly maintain alarm systems

and other security devices, panic buttons,

hand-held alarms or noise devices, cellular

phones, and private channel radios where risk

is apparent or may be anticipated. Arrange

for a reliable response system when an alarm

is triggered.

■ Provide metal detectors—installed or

hand-held, where appropriate—to detect

guns, knives, or other weapons, according to

the recommendations of security consultants.

■ Use a closed-circuit video recording for

high-risk areas on a 24-hour basis. Public

safety is a greater concern than privacy in

these situations.

■ Place curved mirrors at hallway intersections

or concealed areas.

■ Enclose nurses’ stations and install deep

service counters or bullet-resistant, shatterproof glass in reception, triage, and admitting

areas or client service rooms.

■ Provide employee “safe rooms” for use

during emergencies.

■ Establish “time-out” or seclusion areas with

high ceilings without grids for patients who

“act out” and establish separate rooms for

criminal patients.

■ Provide comfortable client or patient waiting

rooms designed to minimize stress.

■ Ensure that counseling or patient care rooms

have two exits.

■ Lock doors to staff counseling rooms and

treatment rooms to limit access.

■ Arrange furniture to prevent entrapment of

staff.
8

■ Use minimal furniture in interview rooms

or crisis treatment areas, and ensure that it is

lightweight, without sharp corners or edges,

and affixed to the floor, if possible. Limit the

number of pictures, vases, ashtrays, or other

items that can be used as weapons.

■ Provide lockable and secure bathrooms for

staff members separate from patient/client

and visitor facilities.

■ Lock all unused doors to limit access, in

accordance with local fire codes.

■ Install bright, effective lighting, both indoors

and outdoors.

■ Replace burned-out lights and broken

windows and locks.

■ Keep automobiles well maintained if they

are used in the field.

■ Lock automobiles at all times.

What administrative and work practice

controls can minimize risk?

Administrative and work practice controls

affect the way staff perform jobs or tasks.

Changes in work practices and administrative

procedures can help prevent violent incidents.

Some options for employers are to:

■ State clearly to patients, clients, and

employees that violence is not permitted or

tolerated.

■ Establish liaison with local police and state

prosecutors. Report all incidents of violence.

Give police physical layouts of facilities to

expedite investigations.

■ Require employees to report all assaults

or threats to a supervisor or manager (for

example, through a confidential interview).

Keep log books and reports of such incidents

to help determine any necessary actions to

prevent recurrences.

■ Advise employees of company procedures for

requesting police assistance or filing charges

when assaulted, and help them do so, if

necessary.

■ Provide management support during

emergencies. Respond promptly to all

complaints.

■ Set up a trained response team to respond

to emergencies.

■ Use properly trained security officers to deal

with aggressive behavior. Follow written

security procedures.

■ Ensure that adequate and properly trained

staff are available to restrain patients or

clients, if necessary.

■ Provide sensitive and timely information to

people waiting in line or in waiting rooms.

Adopt measures to decrease waiting time.

■ Ensure that adequate and qualified staff are

available at all times. Times of greatest risk

occur during patient transfers, emergency

responses, mealtimes, and at night. Areas

with the greatest risk include admission units

and crisis or acute-care units.

■ Institute a sign-in procedure with passes for

visitors, especially in a newborn nursery or

pediatric department. Enforce visitor hours

and procedures.

■ Establish a list of “restricted visitors” for

patients with a history of violence or gang

activity. Make copies available at security

checkpoints, nurses’ stations, and visitor

sign-in areas.

■ Review and revise visitor check systems,

when necessary. Limit information about

hospitalized victims of violence given to

outsiders.

■ Supervise the movement of psychiatric

clients and patients throughout the facility.

■ Control access to facilities other than

waiting rooms, particularly drug storage or

pharmacy areas.

■ Prohibit employees from working alone

in emergency areas or walk-in clinics,
9

particularly at night or when assistance is

unavailable. Do not allow employees to

enter seclusion rooms alone.

■ Establish policies and procedures for

secured areas and emergency evacuations.

■ Determine the behavioral history of new

and transferred patients to learn about any

past violent or assaultive behaviors.

■ Establish a system—such as chart tags,

log books, or verbal census reports—to

identify patients and clients with assaultive

behavior problems. Keep in mind patient

confidentiality and worker safety issues.

Update as needed.

■ Treat and interview aggressive or agitated

clients in relatively open areas that still

maintain privacy and confidentiality (such

as rooms with removable partitions).

■ Use case management conferences with

coworkers and supervisors to discuss ways

to effectively treat potentially violent patients.

■ Prepare contingency plans to treat clients

who are “acting out” or making verbal or

physical attacks or threats. Consider using

certified employee assistance professionals

or in-house social-service or occupational

health-service staff to help diffuse patient

or client anger.

■ Transfer assaultive clients to acute care units,

criminal units, or other more restrictive

settings.

■ Ensure that nurses and physicians are not

alone when performing intimate physical

examinations of patients.

■ Discourage employees from wearing

necklaces or chains to help prevent possible

strangulation in confrontational situations.

Urge community workers to carry only

required identification and money.

■ Survey the facility periodically to remove

tools or possessions left by visitors or

maintenance staff that could be used

inappropriately by patients.

■ Provide staff with identification badges,

preferably without last names, to readily

verify employment.

■ Discourage employees from carrying keys,

pens, or other items that could be used as

weapons.

■ Provide staff members with security escorts

to parking areas in evening or late hours.

Ensure that parking areas are highly visible,

well lit, and safely accessible to the building.

■ Use the “buddy system,” especially when

personal safety may be threatened. Encourage

home health-care providers, social-service

workers, and others to avoid threatening

situations.

■ Advise staff to exercise extra care in

elevators, stairwells, and unfamiliar

residences; leave the premises immediately

if there is a hazardous situation; or request

police escort if needed.

■ Develop policies and procedures covering

home health-care providers, such as contracts

on how visits will be conducted, the presence

of others in the home during the visits, and

the refusal to provide services in a clearly

hazardous situation.

■ Establish a daily work plan for field staff to

keep a designated contact person informed

about their whereabouts throughout the

workday. Have the contact person follow up

if an employee does not report in.

How should an employer respond

to an incident of violence?

Post-incident response and evaluation are

essential to an effective violence prevention

program. All workplace violence programs

should provide comprehensive treatment for

employees who are victimized personally or

may be traumatized by witnessing a workplace

violence incident. Injured staff should receive

prompt treatment and psychological evaluation

whenever an assault takes place, regardless of
10

its severity. Provide the injured transportation

to medical care if it is not available onsite.

Victims of workplace violence suffer a variety

of consequences in addition to their actual

physical injuries. These may include:

■ Short- and long-term psychological trauma;

■ Fear of returning to work;

■ Changes in relationships with coworkers

and family;

■ Feelings of incompetence, guilt, powerlessness;

and

■ Fear of criticism by supervisors or managers.

Consequently, a strong follow-up program

for these employees will not only help them to

deal with these problems but also help prepare

them to confront or prevent future incidents

of violence.

Several types of assistance can be incorporated

into the post-incident response. For example,

trauma-crisis counseling, critical-incident

stress debriefing, or employee assistance

programs may be provided to assist victims.

Certified employee assistance professionals,

psychologists, psychiatrists, clinical nurse

specialists, or social workers may provide this

counseling, or the employer may refer staff

victims to an outside specialist. In addition, the

employer may establish an employee counseling

service, peer counseling, or support groups.

Counselors should be well trained and

have a good understanding of the issues and

consequences of assaults and other aggressive,

violent behavior. Appropriate and promptly

rendered post-incident debriefings and

counseling reduce acute psychological trauma

and general stress levels among victims and

witnesses. In addition, this type of counseling

educates staff about workplace violence

and positively influences workplace and

organizational cultural norms to reduce

trauma associated with future incidents.

Safety and Health Training

How can training help reduce the

risk of violence?

Training and education ensure that all staff

are aware of potential security hazards and

how to protect themselves and their coworkers

through established policies and procedures.

What training should all

employees receive?

Every employee should understand the concept

of “universal precautions for violence”— that

is, that violence should be expected but can

be avoided or mitigated through preparation.

Frequent training also can reduce the likelihood

of being assaulted.

Employees who may face safety and security

hazards should receive formal instruction on

the specific hazards associated with the unit or

job and facility. This includes information on

the types of injuries or problems identified in

the facility and the methods to control the

specific hazards. It also includes instructions

to limit physical interventions in workplace

altercations whenever possible, unless enough

staff or emergency response teams and security

personnel are available. In addition, all

employees should be trained to behave

compassionately toward coworkers when

an incident occurs.

The training program should involve all

employees, including supervisors and managers.

New and reassigned employees should receive

an initial orientation before being assigned their

job duties. Visiting staff, such as physicians,

should receive the same training as permanent

staff. Qualified trainers should instruct at the

comprehension level appropriate for the staff.

Effective training programs should involve role

playing, simulations, and drills.

Topics may include management of assaultive

behavior, professional assault-response training,

police assault-avoidance programs, or personal

safety training such as how to prevent and
11

avoid assaults. A combination of training may

be used depending on the severity of the risk.

Employees should receive required training

annually. In large institutions, refresher

programs may be needed more frequently,

perhaps monthly or quarterly, to effectively

reach and inform all employees.

What should training cover?

The training should cover topics such as:

■ The workplace violence prevention policy;

■ Risk factors that cause or contribute to

assaults;

■ Early recognition of escalating behavior or

recognition of warning signs or situations

that may lead to assaults;

■ Ways to prevent or diffuse volatile situations

or aggressive behavior, manage anger, and

appropriately use medications as chemical

restraints;

■ A standard response action plan for violent

situations, including the availability of

assistance, response to alarm systems, and

communication procedures;

■ Ways to deal with hostile people other than

patients and clients, such as relatives and

visitors;

■ Progressive behavior control methods and

safe methods to apply restraints;

■ The location and operation of safety devices

such as alarm systems, along with the

required maintenance schedules and

procedures;

■ Ways to protect oneself and coworkers,

including use of the “buddy system;”

■ Policies and procedures for reporting and

recordkeeping;

■ Information on multicultural diversity to

increase staff sensitivity to racial and ethnic

issues and differences; and

■ Policies and procedures for obtaining medical

care, counseling, workers’ compensation, or

legal assistance after a violent episode or injury.

What training should supervisors

and managers receive?

Supervisors and managers need to learn

to recognize high-risk situations, so they

can ensure that employees are not placed in

assignments that compromise their safety.

They also need training to ensure that they

encourage employees to report incidents.

Supervisors and managers should learn

how to reduce security hazards and ensure

that employees receive appropriate training.

Following training, supervisors and managers

should be able to recognize a potentially

hazardous situation and to make any necessary

changes in the physical plant, patient care

treatment program, and staffing policy and

procedures to reduce or eliminate the

hazards.

What training do security

personnel require?

Security personnel need specific training

from the hospital or clinic, including the

psychological components of handling

aggressive and abusive clients, types of

disorders, and ways to handle aggression

and defuse hostile situations.

The training program should also include

an evaluation. At least annually, the team

or coordinator responsible for the program

should review its content, methods, and the

frequency of training. Program evaluation

may involve supervisor and employee

interviews, testing and observing, and

reviewing reports of behavior of individuals

in threatening situations.
12

Recordkeeping and Program

Evaluation

How can an employer determine

the program’s effectiveness?

Recordkeeping and evaluation of the violence

prevention program are necessary to determine

its overall effectiveness and identify any

deficiencies or changes that should be made.

What records should employers keep?

Recordkeeping is essential to the program’s

success. Good records help employers determine

the severity of the problem, evaluate methods

of hazard control, and identify training needs.

Records can be especially useful to large

organizations and for members of a business

group or trade association who “pool” data.

Records of injuries, illnesses, accidents, assaults,

hazards, corrective actions, patient histories,

and training can help identify problems and

solutions for an effective program.

Important Records:

■ OSHA Log of Work-Related Injury and

Illness (OSHA 300). Employers who are

required to keep this log must record any

new work-related injury that results in death,

days away from work, days of restriction or

job transfer, medical treatment beyond first

aid, loss of consciousness, or a significant

injury diagnosed by a licensed health-care

professional. Injuries caused by assaults

must be entered on the log if they meet the

recording criteria. All employers must report,

within 24 hours, a fatality or an incident that

results in the hospitalization of three or

more employees.8

■ Medical reports of work injury and supervisors’

reports for each recorded assault. These

records should describe the type of assault,

such as an unprovoked sudden attack or

patient-to-patient altercation; who was

assaulted; and all other circumstances of

the incident. The records should include a

description of the environment or location,

potential or actual cost, lost worktime that

resulted, and the nature of injuries sustained.

These medical records are confidential

documents and should be kept in a locked

location under the direct responsibility of a

health-care professional.

■ Records of incidents of abuse, verbal

attacks, or aggressive behavior that may

be threatening, such as pushing or shouting

and acts of aggression toward other clients.

This may be kept as part of an assaultive

incident report. Ensure that the affected

department evaluates these records routinely.

(See sample incident forms in Appendix B.)

■ Information on patients with a history of

past violence, drug abuse, or criminal activity

recorded on the patient’s chart. All staff who

care for a potentially aggressive, abusive,

or violent client should be aware of the

person’s background and history. Log the

admission of violent patients to help

determine potential risks.

■ Documentation of minutes of safety

meetings, records of hazard analyses, and

corrective actions recommended and taken.

■ Records of all training programs, attendees,

and qualifications of trainers.

What should a program evaluation

involve?

As part of their overall program, employers

should evaluate their safety and security

measures. Top management should review

the program regularly, and with each incident,

to evaluate its success. Responsible parties

(including managers, supervisors, and

employees) should reevaluate policies and

procedures on a regular basis to identify

deficiencies and take corrective action.

8 Title 29 Code of Federal Regulations (CFR),

Part 1904, revised 2001.
13

Management should share workplace

violence prevention evaluation reports with all

employees. Any changes in the program should

be discussed at regular meetings of the safety

committee, union representatives, or other

employee groups.

All reports should protect employee

confidentiality either by presenting only

aggregate data or by removing personal

identifiers if individual data are used.

Processes involved in an evaluation include:

■ Establishing a uniform violence reporting

system and regular review of reports;

■ Reviewing reports and minutes from staff

meetings on safety and security issues;

■ Analyzing trends and rates in illnesses,

injuries, or fatalities caused by violence

relative to initial or “baseline” rates;

■ Measuring improvement based on lowering

the frequency and severity of workplace

violence;

■ Keeping up-to-date records of administrative

and work practice changes to prevent

workplace violence to evaluate how well

they work;

■ Surveying employees before and after making

job or worksite changes or installing security

measures or new systems to determine their

effectiveness;

■ Keeping abreast of new strategies available

to deal with violence in the health-care and

social-service fields as they develop;

■ Surveying employees periodically if they

experience hostile situations about the medical

treatment they received;

■ Complying with OSHA and state requirements

for recording and reporting deaths, injuries,

and illnesses; and

■ Requesting periodic law enforcement or

outside consultant review of the worksite for

recommendations on improving employee

safety.

Where can employers find sources

of assistance?

Employers who would like help in

implementing an appropriate workplace

violence prevention program can turn to the

OSHA Consultation Service provided in their

state. To contact this service, see OSHA’s

website at www.osha.gov or call (800)

321–OSHA.

OSHA’s efforts to help employers combat

workplace violence are complemented by

those of NIOSH, public safety officials, trade

associations, unions, insurers, and human

resource and employee assistance professionals,

as well as other interested groups. Employers

and employees may contact these groups for

additional advice and information. NIOSH

can be reached toll-free at (800) 35–NIOSH.
14

Conclusion

OSHA recognizes the importance of effective

safety and health program management in

providing safe and healthful workplaces.

Effective safety and health programs improve

both morale and productivity and reduce

workers’ compensation costs.

OSHA’s violence prevention guidelines

are an essential component to workplace

safety and health programs. OSHA believes

the performance-oriented approach of these

guidelines provides employers with flexibility

in their efforts to maintain safe and healthful

working conditions.

14
15

References

California State Department of Industrial

Relations, Cal/OSHA. (1998). Guidelines

for Security and Safety of Health Care and

Community Service Workers. www.dir.ca.gov/

dosh/dosh%5Fpublications/hcworker.html

Centers for Disease Control and Prevention,

National Institute for Occupational Health.

(2002). Occupational Hazards in Hospitals.

DHHS (NIOSH) Pub. No. 2002-101.

www.cdc.gov/niosh/2002-101.html

U.S. Department of Justice, Bureau of Justice

Statistics. (2001). National Crime Victimization

Survey. Violence in the Workplace, 1993–99.

www.ojp.gov/bjs/pub/pdf/vw99.pdf

U.S. Department of Labor, Bureau of Labor

Statistics. (2002). Census of Fatal Occupational

Injuries, 2001. www.bls.gov/iif/oshwc/cfoi/

cfnr0008.pdf

U.S. Department of Labor, Bureau of Labor

Statistics. (2001). Survey of Occupational

Injuries and Illnesses, 2000. www.bls.gov/iif/

oshwc/osh/os/osnr0013.pdf

Washington, Department of Labor and

Industries. Workplace Violence: Awareness

and Prevention for Employers and Employees,

2000. www.lni.wa.gov/ipub/417-140-000.htm
17

Appendix A:

Workplace Violence Program Checklists

Reprinted with permission of the American Nurses Association, Promoting Safe Work

Environments for Nurses, 2002.

Checklist 1:

Organizational Assessment Questions Regarding Management

Commitment and Employee Involvement

■ Are front-line workers included as regular

members and participants in the safety

committee as well as violence tracking

activities?

■ Does the tracking and reporting capture

all types of violence—fatalities, physical

assaults, harassment, aggressive behavior,

threats, verbal abuse, and sexual assaults?

■ Does the tracking and reporting system use

the latest categories of violence so data can

be compared?

■ Have the high-risk locations or jobs with

the greatest risk of violence as well as

the processes and procedures that put

employees at risk been identified?

■ Is there a root-cause analysis of the risk

factors associated with individual violent

incidents so that current response systems

can be addressed and hazards can be

eliminated and corrected?

■ Are employees consulted about what

corrective actions need to be taken for

single incidents or surveyed about violence

concerns in general?

■ Is there follow-up of employees involved

in or witnessing violent incidents to assure

that appropriate medical treatment and

counseling have been provided?

■ Has a process for reporting violent

incidents within the facility to the police

or requesting police assistance been

established?

■ Is there demonstrated organizational concern

for employee emotional and physical safety

and health as well as that of the patients?

■ Is there a written workplace violence

prevention program in your facility?

■ Did front-line workers as well as management

participate in developing the plan?

■ Is there someone clearly responsible for the

violence prevention program to ensure that

all managers, supervisors, and employees

understand their obligations?

■ Do those responsible have sufficient authority

and resources to take all action necessary to

ensure worker safety?

■ Does the violence prevention program

address the kinds of violent incidents that

are occurring in your facility?

■ Does the program provide for post-assault

medical treatment and psychological counseling

for health-care workers who experience or

witness assaults or violence incidents?

■ Is there a system to notify employees

promptly about specific workplace

security hazards or threats that are made?

Are employees aware of this system?

■ Is there a system for employees to inform

management about workplace security

hazards or threats without fear of reprisal?

Are employees aware of this system?

■ Is there a system for employees to promptly

report violent incidents, “near misses,” threats,

and verbal assaults without fear of reprisal?

■ Is there tracking, trending, and regular

reporting on violent incidents through the

safety committee?
18

Checklist 2:

Analyze Workplace Violence Records

■ How many incidents occurred in the last

2 years?

■ What kinds of incidents occurred most

often (assault, threats, robbery, vandalism,

etc.)?

■ Where did incidents most often occur?

■ When did incidents most often occur

(day of week, shift, time, etc.)?

■ What job task was usually being

performed when an incident occurred?

■ Which workers were victimized most

often (gender, age, job classification,

etc.)?

■ What type of weapon was used most

often?

■ Are there any similarities among the

assailants?

■ What other incidents, if any, are you

aware of that are not included in the

records?

■ Of those incidents you reviewed, which

one or two were most serious?

Use the data collected to stimulate the

following discussions:

■ Are there any important patterns or

trends among the incidents?

■ What do you believe were the main

factors contributing to violence in your

workplace?

■ What additional corrective measures

would you recommend to reduce or

eliminate the problems you identified?

Identifying Risks for Violence

by Unit /Work Area

Perform a step-by-step review of each work

area to identify specific places and times that

violent incidents are occurring and the risk

factors that are present. To ensure multiple

perspectives, it is best for a team to perform

this worksite analysis. Key members of the

analysis team should be front-line health-care

workers, including nurses from each specialty

unit, as well as the facility’s safety and security

professionals.

Find Out What’s Happening on Paper

The first step in this worksite analysis is

to obtain and review data that tells the “who,

what, when, where, and why” about violent

incidents. These sources include:

■ Incident report forms

■ Workers’ compensation reports of injury

■ OSHA 300 injury and illness logs

■ Security logs

■ Reports to police

■ Safety committee reports

■ Hazard inspection reports

■ Staff termination records

■ Union complaints

Using this information, attempt to answer

the questions in Checklist 2.

Conduct a Walkthrough

It is important to keep in mind that injuries

from violence are often not reported. One of

the best ways to observe what is really going

on is to conduct a workplace walkthrough.

A walkthrough, which is really a workplace

inspection, is the first step in identifying

violence risk factors and serves several

important functions. While on a walkthrough,

hazards can be recognized and often corrected

before anyone’s health and safety is affected.

While inspecting for workplace violence risk

factors, review the physical facility and note

the presence or absence of security measures.

Local police may also be able to conduct a

security audit or provide information about

experience with crime in the area.
19

Checklist 3:

Identifying Environmental Risk Factors for Violence

■ Given the history of violence at the facility,

is a metal detector appropriate in some

entry areas? Closed-circuit TV in high-risk

areas?

■ Is there good lighting?

■ Are fire exits and escape routes clearly

marked?

■ Are reception and work areas designed

to prevent unauthorized entry? Do they

provide staff good visibility of patients and

visitors? If not, are there other provisions

such as security cameras or mirrors?

■ Are patient or client areas designed to

minimize stress, including minimizing noise?

■ Are drugs, equipment, and supplies

adequately secured?

■ Is there a secure place for employees to

store their belongings?

■ Are “safe rooms” available for staff use

during emergencies?

■ Are door locks in patient rooms appropriate?

Can they be opened during an emergency?

■ Do counseling or patient care rooms have

two exits, and is furniture arranged to

prevent employees from becoming trapped?

■ Are lockable and secure bathrooms that

are separate from patient-client and visitor

facilities available for staff members?

Use the following checklist to assist in

your workplace walkthrough.

General questions about approach:

■ Are safety and security issues specifically

considered in the early stages of facility

design, construction, and renovation?

■ Does the current violence prevention

program provide a way to select and

implement controls based on the specific

risks identified in the workplace security

analysis? How does this process occur?

Specific questions about the environment:

■ Do crime patterns in the neighborhood

influence safety in the facility?

■ Do workers feel safe walking to and from

the workplace?

■ Are entrances visible to security personnel

and are they well lit and free of hiding

places?

■ Is there adequate security in parking or

public transit waiting areas?

■ Is public access to the building controlled,

and is this system effective?

■ Can exit doors be opened only from the

inside to prevent unauthorized entry?

■ Is there an internal phone system to

activate emergency assistance?

■ Have alarm systems or panic buttons been

installed in high-risk areas?
20

Checklist 4:

Assessing the Influence of

Day-to-Day Work Practices on

Occurrences of Violence

■ Are identification tags required for both

employees and visitors to the building?

■ Is there a way to identify patients with a

history of violence? Are contingency plans

put in place for these patients—such as

restricting visitors and supervising their

movement through the facility?

■ Are emergency phone numbers and

procedures posted or readily available?

■ Are there trained security personnel

accessible to workers in a timely manner?

■ Are waiting times for patients kept as

short as possible to avoid frustration?

■ Is there adequate and qualified staffing

at all times, particularly during patient

transfers, emergency responses,

mealtimes, and at night?

■ Are employees prohibited from entering

seclusion rooms alone or working alone

in emergency areas of walk-in clinics,

particularly at night or when assistance

is unavailable?

■ Are broken windows, doors, locks, and

lights replaced promptly?

■ Are security alarms and devices tested

regularly?

Ask the Workers

A simple survey can provide valuable

information often not found in department

walkthroughs and injury logs. Some staff may

not report violent acts or threatening situations

formally but will share the experiences and

suggestions anonymously. This can provide

information about previously unnoticed

deficiencies or failures in work practices

or administrative controls. It also can help

increase employee awareness about dangerous

conditions and encourage them to become

involved in prevention activities.

Types of questions that employees should be

asked include:

■ What do they see as risk factors for violence?

◆ The most important risk factors in their

work areas

◆ Aspects of the physical environment that

contribute to violence

◆ Dangerous situations or “near misses”

experienced

◆ Assault experiences— past year, entire time

at facility

◆ Staffing adequacy

■ How are current control measures working?

◆ Hospital practices for handling conflict

among staff and patients

◆ Effectiveness of response to violent

incidents

◆ How safe they feel in the current

environment

■ What ideas do employees have to protect

workers?

◆ Highest priorities in violence prevention

◆ Ideas for improvements and prevention

measures

■ How satisfied are they in their jobs?

◆ With managers/fellow workers

◆ Adequacy of rewards and praise

◆ Impact on health

Checklist 5:

Post-Incident Response

■ Is comprehensive treatment provided to

victimized employees as well as those

who may be traumatized by witnessing a

workplace violence incident? Required

services may include trauma-crisis

counseling, critical incident stress debriefing, psychological counseling services,

peer counseling, and support groups.
21

Checklist 6:

Assessing Employee and

Supervisor Training

■ Does the violence prevention program

require training for all employees and

supervisors when they are hired and

when job responsibilities change?

■ Do agency workers or contract physicians

and house staff receive the same training

that permanent staff receive?

■ Are workers trained in how to handle

difficult clients or patients?

■ Does the security staff receive specialized

training for the health-care environment?

■ Is the training tailored to specific units,

patient populations, and job tasks,

including any tasks done in the field?

■ Do employees learn progressive behavior

control methods and safe methods to

apply restraints?

■ Do workers believe that the training is

effective in handling escalating violence

or violent incidents?

■ Are drills conducted to test the response

of health-care facility personnel?

■ Are workers trained in how to report

violent incidents, threats, or abuse and

obtain medical care, counseling, workers’

compensation, or legal assistance after a

violent episode or injury?

■ Are employees and supervisors trained

to behave compassionately toward

coworkers when an incident occurs?

■ Does the training include instruction

about the location and operation of

safety devices such as alarm systems,

along with the required maintenance

schedules and procedures?

Checklist 7:

Recordkeeping and Evaluation

Does the violence prevention program

provide for:

■ Up-to-date recording in the OSHA Log

of Work-Related Injury and Illness

(OSHA 300)?

■ Records of all incidents involving assault,

harassment, aggressive behavior, abuse,

and verbal attack with attention to

maintaining appropriate confidentiality

of the records?

■ Training records?

■ Workplace walkthrough and security

inspection records?

■ Keeping records of control measures

instituted in response to inspections,

complaints, or violent incidents?

■ A system for regular evaluation of

engineering, administrative, and work

practice controls to see if they are

working well?

■ A system for regular review of

individual reports and trending and

analysis of all incidents?

■ Employee surveys regarding the

effectiveness of control measures

instituted?

■ Discussions with employees who are

involved in hostile situations to ask

about the quality of post-incident

treatment they received?

■ A provision for an outside audit or

consultation of the violence programs

for recommendations on improving

safety?
22

Appendix B

Violence Incident Report Forms

Signature Date

Sample 1

The following items serve merely as an example of what might be used or modified by employers in these industries

to help prevent workplace violence.

(Sample/Draft—Adapt to your own location and business circumstances.)

Confidential Incident Report

To: Date of Incident:

Location of Incident (Map/sketch on reverse side or attached):

From: Phone: Time of Incident:

Nature of the Incident (“X” all applicable boxes):

❑ Assaults or Violent Acts: Type “l” Type “2” Type “3” Other

❑ Preventative or Warning Report

❑ Bomb or Terrorist Type Threat ❑ Yes ❑ No

❑ Transportation Accident

❑ Contacts with Objects or Equipment

❑ Falls

❑ Exposures

❑ Fires or Explosions

❑ Other

Legal Counsel Advised of Incident? ❑ Yes ❑ No EAP Advised? ❑ Yes ❑ No

Warning or Preventative Measures? ❑ Yes ❑ No

Number of Persons Affected:

(For each person, complete a report; however, to the extent facts are duplicative, any person’s report may

incorporate another person’s report.)

Name of Affected Person(s): Service Date:

Position: Member of Labor Organization? ❑ Yes ❑ No

Supervisor: Has Supervisor Been Notified? ❑ Yes ❑ No

Family: Has Been Notified by: ? ❑ Yes ❑ No

Lost Work Time? ❑ Yes ❑ No Anticipated Return to Work:

Third parties or non-employee involvement (include contractor and lease employees, visitors, vendors,

customers)? ❑ Yes ❑ No

Nature of the Incident

Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3) location details;

(4) equipment/weapon details; (5) weather; (6) other records of the incident (e.g., police report, recordings,

videos); (7) the ability to observe and reliability of witnesses; (8) were the parties possibly impaired because of

illness, injury, drugs or alcohol? (were tests taken to verify same?); (9) parties notified internally (employee

relations, medical, legal, operations, etc.) and externally (police, fire, ambulance, EAP, family, etc.).

Previous or Related Incidents of This Type? ❑ Yes ❑ No Or by This Person? ❑ Yes ❑ No

Preventative Steps? ❑ Yes ❑ No OSHA Log or Other OSHA Action Required? ❑ Yes ❑ No

Incident Response Team:

Team Leader: 

Source: Reprinted with permission of Karen Smith Keinbaum, Esq., Counsel to the Law Firm of Abbott, Nicholson, Quilter, Esshaki

& Youngblood, P. C., Detroit, MI.
23

Sample 2

The following items serve merely as an example of what might be used or modified by employers in these

industries to help prevent workplace violence.

A reportable violent incident should be defined as any threatening remark or overt act of physical violence

against a person(s) or property whether reported or observed.

1. Date: 2. Specific Location:

Day of Week:

Time:

Assailant: ❑ Female ❑ Male

3. Violence Directed Toward: ❑ Patient ❑ Staff ❑ Visitor ❑ Other

Assailant: ❑ Patient ❑ Staff ❑ Visitor ❑ Other

Assailant’s Name: 

Assailant: ❑ Unarmed ❑ Armed (weapon)

4. Predisposing Factors:

❑ Intoxication ❑ Dissatisfied with Care/Waiting Time

❑ Grief Reaction ❑ Prior History of Violence

❑ Gang Related

❑ Other (Describe)

5. Description of Incident: 6. Injuries: 7. Extent of Injuries:

❑ Physical Abuse ❑ Yes

❑ Verbal Abuse ❑ No

❑ Other

8. Detailed Description of the Incident:

9. Did Any Person Leave the Area because of Incident?

❑ Yes ❑ No ❑ Unable to Determine

10. Present at Time of Incident:

❑ Police Name of Department

❑ Hospital Security Officer

11. Needed to Call:

❑ Police Name of Department

❑ Hospital Security

12. Termination of Incident:

Incident Diffused ❑ Yes ❑ No

Police Notified ❑ Yes ❑ No

Assailant Arrested ❑ Yes ❑ No

13. Disposition of Assailant: 14. Restraints Used: ❑ Yes ❑ No

Stayed on Premises ❑

Escorted off Premises ❑ Type:

Left on Own ❑

Other ❑ 

15. Report Completed By: Title:

Witnesses:

Supervisor Notified: Time:

Please put additional comments, according to numbered section, on reverse side of form.

Source: Reprinted with permission of the Metropolitan Chicago Healthcare Council, Guidelines for Dealing with Violence in

Health Care, Chicago, IL, 1995.
24

Appendix C

Suggested Readings

Alspach, G. (1993). “Nurses as Victims of

Violence.” Critical Care Nurse 13(5):13–17.

Biles, P.D. (1997). “OSHA’s Guidelines

for Protecting Health Care Workers from

Workplace Violence.” Joint Commission on

Accreditation of Healthcare Organizations:

Environment of Care/PTSM Series 3:29–35.

Cal/OSHA. (1998). “Guidelines for Security

and Safety of Health Care and Community

Service Workers.” www.dir.ca.gov/dosh/

dosh%5Fpublications/hcworker.html

Carroll, V. and Morin, K.H. (1998).

“Workplace Violence Affects One-Third of

Nurses.” nursingworld.org/tan/98sepoct/

violence.htm

Centers for Disease Control and Prevention,

National Institute for Occupational Health.

(2002). “Occupational Hazards in Hospitals.”

DHHS (NIOSH) Pub. No. 2002–101.

www.cdc.gov/niosh/2002-101.html

Centers for Disease Control and Prevention,

National Institute for Occupational Safety

and Health. (1996). “Violence in the

Workplace: Risk Factors and Preventive

Strategies.” Current Intelligence Bulletin 57,

DHHS (NIOSH) Pub. No. 96-100.

www.cdc.gov/niosh/violcont.html

Colling, R.L. (1997). “Controlling

Workplace Violence: A Security Management

Plan Approach.” Joint Commission on

Accreditation of Healthcare Organizations:

Environment of Care/PTSM Series 3:37–47.

Colorado Nurses Association, Task Force

on Workplace Violence. (1998). “Survey

on Workplace Violence of Nurses in Seven

State Nurses Associations.” Available from

Colorado Nurses Association, Denver, CO.

www.nurses-co.org

Davis, S. (1991). “Violence in Psychiatric

Inpatients: A Review.” Hospital and

Community Psychiatry 42:585–590.

DiBenedetto, D.V. (1992). “Occupational

Hazards of the Healthcare Industry: Protecting

Healthcare Workers.” AAOHN Journal

43(3):131–137.

Dillon, S. (1992). “Social Workers: Targets

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program’s operating costs. State plans must

provide standards and enforcement programs,

as well as voluntary compliance activities, that

are at least as effective as Federal OSHA’s.

Currently, 26 states and territories have

their own plans. Twenty-three cover both

private and public (state and local government)

employees and three states, Connecticut,

New Jersey, and New York, cover only the

public sector. For more information on state

plans, visit OSHA’s website at www.osha.gov.

What is consultation assistance?

Consultation assistance is available

on request to employers who want help

establishing and maintaining a safe and

healthful workplace. Funded largely by OSHA,

the service is provided at no cost to small

employers and is delivered by state authorities

through professional safety and health

consultants.

What is the Safety and Health

Achievement Recognition Program

(SHARP)?

Under the consultation program, certain

exemplary employers may request participation

in OSHA’s Safety and Health Achievement

Recognition Program (SHARP). Eligibility

for participation includes, but is not limited

to, receiving a full-service, comprehensive

consultation visit, correcting all identified

hazards, and developing an effective safety

and health program management program.

Employers accepted into SHARP may receive

an exemption from programmed inspections (not

complaint or accident investigation inspections)

for 1 year initially, or 2 years upon renewal.

For more information about consultation

assistance, visit OSHA’s website at

www.osha.gov.

How can OSHA help me?

OSHA can provide extensive help through

a variety of programs, including assistance

about safety and health programs, state plans,

workplace consultations, voluntary protection

programs, strategic partnerships, alliances, and

training and education. An overall commitment

to workplace safety and health can add value

to your business, to your workplace, and to

your life.

How does safety and health

management system assistance help

employers and employees?

Working in a safe and healthful environment

can stimulate innovation and creativity and

result in increased performance and higher

productivity. The key to a safe and healthful

work environment is a comprehensive safety

and health management system.

OSHA has electronic compliance assistance

tools, or eTools, on its website that “walk”

users through the steps required to develop

a comprehensive safety and health program.

The eTools are posted at www.osha.gov and

are based on guidelines that identify four

general elements critical to a successful safety

and health management system:

■ Management leadership and employee

involvement;

■ Worksite analysis;

■ Hazard prevention and control; and

■ Safety and health training.

What are state programs?

The Occupational Safety and Health Act of

1970 (OSH Act) encourages states to develop

and operate their own job safety and health

plans. OSHA approves and monitors these

plans and funds up to 50 percent of each

Appendix D

OSHA Assistance, Services, and Programs
27

What are the Voluntary Protection

Programs (VPPs)?

Voluntary Protection Programs are designed

to recognize outstanding achievements by

companies that have developed and implemented

effective safety and health management programs.

There are three levels of VPPs: Star, Merit,

and Demonstration. All are designed to

achieve the following goals:

■ Recognize employers that have successfully

developed and implemented effective and

comprehensive safety and health management

programs;

■ Encourage these employers to continuously

improve their safety and health management

programs;

■ Motivate other employers to achieve excellent

safety and health results in the same outstanding

way; and

■ Establish a cooperative relationship between

employers, employees, and OSHA.

VPP participation can bring many benefits

to employers and employees, including fewer

worker fatalities, injuries, and illnesses;

lost-workday case rates generally 50 percent

below industry averages; and lower workers’

compensation and other injury- and illnessrelated costs. In addition, many VPP sites report

improved employee motivation to work safely,

leading to a better quality of life at work;

positive community recognition and interaction;

further improvement and revitalization of

already-good safety and health programs;

and a positive relationship with OSHA.

After a site applies for the program, OSHA

reviews an employer’s VPP application and

conducts a VPP onsite evaluation to verify

that the site’s safety and health management

programs are operating effectively. OSHA

conducts onsite evaluations on a regular basis,

annually for participants at the Demonstration

level, every 18 months for Merit, and every 3

to 5 years for Star. Once a year, all participants

must send a copy of their most recent annual

internal evaluation to their OSHA regional

office. This evaluation must include the worksite’s

record of injuries and illnesses for the past year.

Sites participating in VPP are not scheduled

for regular, programmed inspections. OSHA

does, however, handle any employee complaints,

serious accidents, or significant chemical

releases that may occur at VPP sites according

to routine enforcement procedures.

For more information, visit OSHA’s website

at www.osha.gov.

How can a partnership with OSHA

improve worker safety and health?

OSHA has learned firsthand that voluntary,

cooperative partnerships with employers,

employees, and unions can be a useful

alternative to traditional enforcement and an

effective way to reduce worker deaths, injuries,

and illnesses. This is especially true when a

partnership leads to the development and

implementation of a comprehensive workplace

safety and health management program.

What is OSHA’s Strategic Partnership

Program (OSPP)?

OSHA Strategic Partnerships are agreements

among labor, management, and government to

improve workplace safety and health. These

partnerships encourage, assist, and recognize

the efforts of the partners to eliminate serious

workplace hazards and achieve a high level

of worker safety and health. Whereas OSHA’s

Consultation Program and VPP entail one-on-one

relationships between OSHA and individual

worksites, most strategic partnerships build

cooperative relationships with groups of

employers and employees.

There are two major types of OSPPs.

Comprehensive partnerships focus on

establishing comprehensive safety and health

management systems at partnering worksites.

Limited partnerships help identify and eliminate
28

hazards associated with worker deaths,

injuries, and illnesses, or have goals other

than establishing comprehensive worksite

safety and health programs.

For more information about this program,

visit the agency’s website at www.osha.gov.

What occupational safety and health

training does OSHA offer?

The OSHA Training Institute provides basic

and advanced training and education in safety

and health for federal and state compliance

officers, state consultants, other federal agency

personnel, and private sector employers,

employees, and their representatives.

What is the OSHA Training

Grant Program?

OSHA awards grants to nonprofit

organizations to provide safety and health

training and education to employers and

workers in the workplace. Grants often focus

on high-risk activities or hazards or may help

nonprofit organizations in training, education,

and outreach.

OSHA expects each grantee to develop a

program that addresses a safety and health

topic named by OSHA, recruit workers and

employers for the training, and conduct the

training. Grantees are also expected to follow

up with students to find out how they applied

the training in their workplaces.

For more information, contact OSHA Office

of Training and Education, 2020 Arlington

Heights Rd., Arlington Heights, IL 60005;

or call (847) 297–4810.

What other assistance materials does

OSHA have available?

OSHA has a variety of materials and tools

on its website at www.osha.gov. These include

eTools such as Expert Advisors and Electronic

Compliance Assistance Tools, information on

specific health and safety topics, regulations,

directives, publications, videos, and other

information for employers and employees.

OSHA also has an extensive publications

program. For a list of free or sales items, visit

OSHA’s website at www.osha.gov or contact

the OSHA Publications Office, U.S. Department

of Labor, 200 Constitution Avenue, NW,

N-3101, Washington, DC 20210. Telephone

(202) 693–1888 or FAX to (202) 693–2498.

In addition, OSHA’s CD-ROM includes

standards, interpretations, directives, and

more. It is available for sale from the

U.S. Government Printing Office. To order,

write to the Superintendent of Documents,

U.S. Government Printing Office, Washington,

DC 20402, or phone (202) 512–1800.

What do I do in case of an emergency or

to file a complaint?

To report an emergency, file a complaint,

or seek OSHA advice, assistance, or products,

call (800) 321–OSHA or contact your nearest

OSHA regional, area, state plan, or consultation

office. The teletypewriter (TTY) number is

(877) 889–5627.

Employees can also file a complaint online

and get more information on OSHA federal

and state programs by visiting OSHA’s website

at www.osha.gov.
29

Region VI

(AR, LA, NM,* OK, TX)

525 Griffin Street, Room 602

Dallas, TX 75202

(214) 767–4731 or 4736 x224

Region VII

(IA,* KS, MO, NE)

City Center Square

1100 Main Street, Suite 800

Kansas City, MO 64105

(816) 426–5861

Region VIII

(CO, MT, ND, SD, UT,* WY*)

1999 Broadway, Suite 1690

P.O. Box 46550

Denver, CO 80202-5716

(303) 844–1600

Region IX

(American Samoa, AZ,* CA,* HI, NV,*

Northern Mariana Islands)

71 Stevenson Street, Room 420

San Francisco, CA 94105

(415) 975–4310

Region X

(AK,* ID, OR,* WA*)

1111 Third Avenue, Suite 715

Seattle, WA 98101-3212

(206) 553–5930

Appendix E

OSHA Regional Office Directory

OSHA Regional Offices

Region I

(CT,* MA, ME, NH, RI, VT*)

JFK Federal Building, Room E340

Boston, MA 02203

(617) 565–9860

Region II

(NJ,* NY,* PR,* VI*)

201 Varick Street, Room 670

New York, NY 10014

(212) 337–2378

Region III

(DE, DC, MD,* PA,* VA,* WV)

The Curtis Center

170 S. Independence Mall West

Suite 740 West

Philadelphia, PA 19106-3309

(215) 861–4900

Region IV

(AL, FL, GA, KY,* MS, NC,* SC,* TN*)

SNAF

61 Forsyth Street SW, Room 6T50

Atlanta, GA 30303

(404) 562–2300

Region V

(IL, IN,* MI,* MN,* OH, WI)

230 South Dearborn Street, Room 3244

Chicago, IL 60604

(312) 353–2220

*These states and territories operate their own

OSHA-approved job safety and health programs.

The Connecticut, New Jersey, and New York plans

cover public employees only. States with approved

programs must have a standard that is identical to

or at least as effective as the federal standard.