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Appendix 4: Workplace Violence - Risk Assessment Form and Samples

Section 1: Context Description — setting the scene

Location	Division
Area/Activity/Person:

 

Section 2: Identifying Hazards — what can go wrong and who will be affected

Hazard	Something with the potential to cause harm	Persons at risk [√]
A		S [ ] V [ ] P [ ] O [ ]
B		S [ ] V [ ] P [ ] O [ ]
C		S [ ] V [ ] P [ ] O [ ]
D		S [ ] V [ ] P [ ] O [ ]

S = staff; V = Visitor, P = Patient; O = Other

Section 3: Existing Control Measures —what practical steps are already in place

Hazard	Existing Control Measures
A
B
C
D

 

Section 4: Evaluating risk — not ‘worse case scenario’; takes into account existing controls

Hazard	Consequence ( 1 – 5 )	X	Likelihood (1 – 5 )	=	Risk Rating (1 – 25 )
				=
				=
				=
				=

 

Section 5: Risk prioritised action plan - applying the hierarchy of controls:

E=eliminate I=isolate M=minimise

Hazard	E /I/ M	Practicable Steps required to further control risk	Responsibility

 

Section 6: Further Information: cross-sector safety responsibilities

Who is responsible for local monitoring?

Is further competent (clinical risk, manual handling) advice required? Yes / No Comments:

Do third parties (agencies) require a copy of this risk assessment for their safety? Yes / No Comments:

 

Section 7: Assessment Sign-Off – assessment monitoring responsibilities

Assessor’s name:

Date of assessment: ___ / ___ / ___

Assessor’s signature:

Review: (tick one) daily weekly monthly yearly

Reassessment date: ___ / ___ / ___

Manager’s signature:

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