|
|
Age
|
|
|
Race
|
|
|
Gender
|
|
|
Number of years in practice
|
|
|
Practice setting:
|
|
|
Population: (Examples: Adults, children, school-based, inpatient/residential, mental health)
|
For each of the statements presented below, please indicate whether you Strongly Agree (SA), Agree (A), Disagree (D), Strongly Disagree, or are Neutral (N), that is you neither Agree or Disagree.
A. I consider client violence toward social workers to be a significant issue for the social work profession in general.
|
1.a
Strongly Agree
Agree
Disagree
Strongly Disagree
Neutral
|
B. Client violence toward social workers is a significant issue in my practice.
|
1.b
Strongly Agree
Agree
Disagree
Strongly Disagree
Neutral
|
|
C. I sometimes worry about my own safety while working with clients.
|
1.c
Strongly Agree
Agree
Disagree
Strongly Disagree
Neutral
|
|
If you Strongly Agree or Agree with this statement, please estimate how many times you worried about your safety in the past year.
|
1. c. 1
|
D. I prefer to not work with clients who are or may be violent.
|
1.d
Strongly Agree
Agree
Disagree
Strongly Disagree
Neutral
|
|
|
2. Concern for my safety on the job causes me to feel (check as many that apply by using the CTRL key):
|
|
|
3. Please identify specific strategies that you use now or have used in the past to stay safe while working with clients in the office.
|
|
|
4. Please identify specific strategies that you use now or have used in the past to stay safe while working with clients on home visits or other field settings.
|
|
|
5. Please identify specific strategies that your agency/employer uses to help you stay safe while working with clients in the office.
|
|
|
6. Please identify specific strategies that your agency/employer uses to help you stay safe while working with clients on home visits or other field settings.
|
|
|
7. Have you ever received any training in how to intervene with violent and potentially violent clients?
Yes
No
|
|
.
|
If Yes, where was the training provided? (check as many that apply using the CTRL button):
|
|
.
|
If you selected 'other' in the above question on training please specify below
|
|
.
|
If you answered Yes to the above question, to what extent did the training meet your needs? (If you attended more than one, please answer about the most recent training)
Fully met my needs
Mostly met my needs
Somewhat met my needs
Not at all
|
|
.
|
If you answered No to question 7, would you want to take part in a training program if it were available? (Yes/No). Why or why not?
|
|
|
8. Does your employer make workplace safety a high priority? Why or Why not?
|
|
|
9. Do you and your colleagues have the opportunity to discuss safety concerns with each other and supervisors on a regular basis?
|
|
|
10. Does your employer use a formal safety policy?
|
|
|
11. Has your employer implemented an agency safety task force?
|
|
|
12. Does your employer support two staff making home visits in high risk situations?
|
|
|
13. Do police or other partner agencies in the community ever accompany you or other staff on home visits in high risk situations?
|
|
|
14. Does your employer have a formal policy about how the agency will respond to staff who have experienced client violence? If so, explain:
|
|
|
Other comments:
|
