Workplace Violence Reporting Form

If you have been a victim of workplace violence, we recommend you follow the MNA’s “Actions You Should Take if Assaulted at Work,” available at https://www.massnurses.org/health-and-safety/current-topics/workplace-violence/actions. You should also file a formal report with your employer.

The Workplace Violence Reporting Form is a formal, written report that gives members the ability to provide the MNA notification of workplace violence incidents and to have follow up with someone regarding the incident if they so choose. Forms submitted will be protected on the MNA’s secure website and faxed forms will be secured in locked files to maintain the confidentiality of submissions, subject to any lawful order compelling release of the information. Data (absent personal identifiers) provided on the forms will be reviewed to identify and analyze trends which can lead to safer practice recommendations. This information will also be an invaluable resource when lobbying for workplace violence legislation, as it will provide documented vs. anecdotal evidence of workplace violence. If you have additional questions, please call the MNA Health & Safety Division at 781-821-4625.

A reportable violent incident is any threatening remark or overt act of physical violence against a person(s) or property. Do not include a patient’s name or any health information that may compromise a patient’s right to privacy. Documentation of Insufficient Staffing/Unsatisfactory Patient Care in Hospital or Community Setting.

Download reporting form as a PDF: Workplace Violence Reporting Form (PDF)