Health Care Assault Log
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1Attention: This form contains information relating to
Health Care Assault Log
Hospitals and ambulatory surgical centers must record the details about each assault
employee health and must be used in a manner that
incident on an employee. Refer to OAR 437-001-0706, and to ORS 654.001 through
protects the confidentiality of employees to the extent
Recordable assaults —
654.295.
possible while the information is being used for
occupational safety and health purposes.
hospitals and related settings
Year:
20
Employer ID number:
Employer Location:
SETTING
EMPLOYEE
INCIDENT
CHECK ONLY ONE box for
each case based on the most
serious outcome for that case:
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)
(L)
(M)
(N)
(O)
(P)
(Q)
(R )
Result of Assaultive
Behavior
Case
Location
H/S/M
Date of
Time of
Specific
Floor
Name of
Job title of
Department or
Status of
Assailant
Possible
Weapon
Number of
Response
Comments
(1)
(2)
(3)
(4)
number
(include
(H-
incident
incident
location
where
employee
this
ward
assailant:
action
cause
(see list)
employees
(see list)
address)
hospital,
where
incident
assaulted
employee
assignment of
(P- patient,
(see list)
(see list)
present
S-
incident
occurred
(see list)
employee
BH- behavioral
(in addition
surgical
occurred
(see list)
health patient,
to victim)
center,
(see list)
V- visitor,
M - home
E- employee,
setting)
O- other)
440-4759 12/07COM
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