Exam Room Violence Hazard Control Checklist Form
Use this checklist to assess and document potential violence hazards and controls within an exam room environment.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exam Room Location/Number
*
Assessor Name
*
First Name
Last Name
Are security measures (e.g., panic buttons, alarms) present and functional?
*
Yes
No
Not Applicable
Are staff trained in de-escalation and violence prevention procedures?
*
All staff trained
Some staff trained
No staff trained
Not Sure
Are emergency exits and evacuation routes clearly marked and accessible?
*
Yes
No
Partially
Are there any identified risk factors (e.g., unsecured objects, poor visibility) present?
*
Unsecured furniture or equipment
Blind spots or poor visibility
Noisy environment
Lack of escape routes
No significant risk factors
Other
Is there a clear protocol for reporting violent incidents?
*
Yes
No
Not Sure
Are environmental controls (e.g., secure storage for sharp objects) in place?
*
All controls in place
Some controls in place
No controls in place
Not Applicable
Have there been any recent incidents of violence in this exam room?
*
Yes, within the last month
Yes, within the last year
No recent incidents
Additional Comments or Observations
Submit Checklist
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