Assessment of Ligature Risks
Completed by:
*
First Name
Last Name
Email
example@example.com
Location:
*
Admin. Blg.
Cartwright
Chestnut
Crestview
Mabee
Rose
Siebert
Sturgis
Other
Room Number / Area
Describe Possible Ligature Point being Assessed:
Patient Profile Rating
*
1
2
3
Low Risk
High Risk
1 is Low Risk, 3 is High Risk
Ligature Point Rating
*
1
2
3
Low Risk
High Risk
1 is Low Risk, 3 is High Risk
Room Designation Rating
*
1
2
3
Low Risk
High Risk
1 is Low Risk, 3 is High Risk
Compensating Factor Rating
*
1
2
3
Low Risk
High Risk
1 is Low Risk, 3 is High Risk
Risk Assessment Score:
Risk Level (0-33=Low / 34-66=Medium / 66-100=HIGH)
Submit
To be completed by Chief Development and Safety Officer
Reviewed
Notes
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Should be Empty: