John Hunter Hospital Emergency Department Aggressive Behaviour to Staff Incident Report Form

Please attached patient label

Date:

Time:

Location of incident (Please tick the appropriate box)

Emergency Room Paediatric Emergency Consult Rooms Triage

Waiting Room Front Desk Single Room 1 or 2 Other

Type of abuse encountered by staff member (Please tick the appropriate box)

Threatened Physical Harm Actual Physical Harm Attempted Staff Member to Staff Member

General Verbal Abuse Weapon Involved Other

Was Security called Was a Duress Alarm activated Please give a brief description of the incident

If an alarm was activated- Fixed Or Personal Duress

Would aggression/de-escalation training have been of benefit Name / Signature (optional) Please return form to the box in NUM2 office – thank you.

Yes/No