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.

First Name
Last Name
Your zip code *
Email address
Phone number
In what type of healthcare facility do you work? *
Name of facility
How long have you worked in healthcare?
How long have you worked with your current employer?
Shift
What is your job title *
Have incidents of workplace violence increased or decreased during the time you have worked at this organization? *
In the last year, have you been directly involved in an incident(s) of workplace violence within this organization? *
If yes, did that incident(s) include any of the following? Check all that apply *
Required
Share your story here
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
If you chose other, please explain
Do you support legislation that forces healthcare facilities to abide by staffing ratios?
Clear selection
Do you believe that forming a healthcare workers' union would help curb violence at your workplace?
Clear selection
In your opinion what would help curb workplace violence in healthcare?
Submit
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