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Workplace Violence Survey
Now more than ever workplace violence plagues healthcare workers in the United States. Our legislators need to know the dangers that we face daily in our facilities. Fill out the survey below to help support federal legislation that will curb violence in our workplaces and protect healthcare workers.
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* Required
First Name
Your answer
Last Name
Your answer
Your zip code
*
Your answer
Email address
Your answer
Phone number
Your answer
In what type of healthcare facility do you work?
*
Choose
Acute care hospital
Long term care facility
Rehabilitation facility
Mental health facity
Other
Name of facility
Your answer
How long have you worked in healthcare?
Your answer
How long have you worked with your current employer?
Your answer
Shift
Choose
Days
Evenings
Nights
Rotates
What is your job title
*
Choose
Registered Nurse
Licensed Practical Nurse
Physicians Assistant
Certified Nursing Assistant / Patient Care Assistant / Patient Care Technician
Physician
Transporter
Medical Assistant
Home Health Aide
Social Worker
Technologist / Technician
Therapist
Security
Other
Have incidents of workplace violence increased or decreased during the time you have worked at this organization?
*
Yes
No
Other:
In the last year, have you been directly involved in an incident(s) of workplace violence within this organization?
*
Yes
No
If yes, did that incident(s) include any of the following? Check all that apply
*
Physical assault – e.g. kicking, punching, spitting, biting, pushing, pulling, cutting, stabbing
Emotional assault -- e.g. bullying, manipulation, intimidation
Sexual assault -- e.g. harassment, stalking
Verbal assault -- e.g. threats, blaming, name-calling unwanted contact
Other – please describe below
Required
Share your story here
Your answer
Rank the factors you think contribute to the problem or threat of violence, or aggression in your work area. Response choice: '1' is the most frequent contributing factor and '5' is the least contributing factor
*
1
2
3
4
5
Mental illness / Drugs and Alcohol ▪
Staffing
Lack of Security and Equipment
Organizational design i.e., wait times, billing
Other
1
2
3
4
5
Mental illness / Drugs and Alcohol ▪
Staffing
Lack of Security and Equipment
Organizational design i.e., wait times, billing
Other
If you chose other, please explain
Your answer
Do you support legislation that forces healthcare facilities to abide by staffing ratios?
Yes
No
Clear selection
Do you believe that forming a healthcare workers' union would help curb violence at your workplace?
Yes
No
Maybe
Clear selection
In your opinion what would help curb workplace violence in healthcare?
Your answer
Submit
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