Checklist template

Staff safety and violence prevention for clinics

A ready-to-use checklist with 113 items in 6 sections, covering Risk assessment, Panic devices, Procedures, Training, Incident reporting, Lone work. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 113 Items
  • 92 Yes / No checks
  • 6 Scored ratings
  • 122 Points

Use this template How audits work

1. Risk assessment 22 items

  1. A written workplace violence risk assessment exists for this clinic Yes / No 1 pt
  2. Date of the last workplace violence risk assessment Date
  3. The assessment was reviewed in the last 12 months or after the last serious incident Yes / No 1 pt
  4. Front-line staff or the safety committee took part in the assessment Yes / No 1 pt
  5. The assessment covers the reception desk, exam rooms, the parking lot and home visits where they are made Yes / No 1 pt
  6. The assessment considers services with higher risk (pain management, behavioral health, urgent care, after-hours clinics) Yes / No 1 pt
  7. The reception counter is deep or high enough that a person cannot reach across to staff Yes / No 1 pt
  8. A barrier or glazing protects reception where the assessment calls for it Yes / No 1 pt
  9. Reception staff have a second way out that does not pass through the waiting room Yes / No 1 pt
  10. Exam room furniture is arranged so the staff member sits nearer the door than the patient Yes / No 1 pt
  11. Exam rooms used for behavioral health visits are free of heavy loose objects within the patient's reach Yes / No 1 pt
  12. Scissors, scalpels and other sharp instruments are kept in drawers, not on open counters in exam rooms Yes / No 1 pt
  13. The waiting room can be seen from the reception desk, directly or by mirror or camera Yes / No 1 pt
  14. Waiting room furniture is heavy or fixed so it cannot be thrown Yes / No 1 pt
  15. Cash, prescription pads and medications are out of sight from the public side Yes / No 1 pt
  16. Lighting works at the staff entrance Yes / No 1 pt
  17. Lighting works across the staff parking area Yes / No 1 pt
  18. Shrubs and fences do not create hiding places beside the staff entrance Yes / No 1 pt
  19. Cameras, where installed, cover the entrance, the waiting room and the staff parking area Yes / No 1 pt
  20. Actions listed in the last assessment have an owner and a due date Yes / No 1 pt
  21. Actions from the last assessment still open Number
  22. Physical layout for staff protection Rating
    • Barriers, sight lines and exits in place 5 pts
    • One of the three is missing at reception or in exam rooms 3 pts
    • Staff can be cornered or reached 1 pt

2. Panic devices 19 items

  1. A panic button is installed at each reception workstation Yes / No 1 pt
  2. A panic button or other alert is available in each exam room or carried by staff Yes / No 1 pt
  3. Consultation rooms used for behavioral health have a panic device within reach of the staff seat Yes / No 1 pt
  4. Panic buttons are positioned where they can be pressed without being seen Yes / No 1 pt
  5. Panic devices were tested at the frequency set by company policy, with a record Yes / No 1 pt
  6. Date of the last panic device test Date
  7. A panic button tested during the visit raised the alarm where expected Yes / No 1 pt
  8. The alarm identifies the room or station it came from Yes / No 1 pt
  9. The alarm sounds or displays in a place that is always staffed during clinic hours Yes / No 1 pt
  10. The alarm company or security service contact list is current Yes / No 1 pt
  11. Staff asked know where the nearest panic device is Yes / No 1 pt
  12. Staff asked know who responds when the alarm is raised Yes / No 1 pt
  13. Personal alarms issued to staff are charged Yes / No 1 pt
  14. Wearable or mobile alarms have a signal in every room, confirmed by a walk test Yes / No 1 pt
  15. A code word or phrase is agreed for calling for help by phone or intercom Yes / No 1 pt
  16. Faulty panic devices reported in the last 12 months were repaired within the time set by company policy Yes / No 1 pt
  17. Panic devices tested during the visit Number
  18. Panic devices that failed the test Number
  19. Panic alarm coverage and function Rating
    • Every station covered and working 5 pts
    • Gaps in coverage or testing 3 pts
    • No working alarm 1 pt

3. Procedures 18 items

  1. A written workplace violence prevention policy is posted or available to staff Yes / No 1 pt
  2. A sign at reception states that abuse of staff is not tolerated Yes / No 1 pt
  3. The patient record can carry a behavior alert visible at check-in Yes / No 1 pt
  4. Patients with a behavior alert are seen with a second staff member nearby or the door ajar, per the care plan Yes / No 1 pt
  5. A written procedure covers warning, behavior agreements and discharge of patients who are violent Yes / No 1 pt
  6. Staff are permitted to end a visit and leave the room when they feel threatened Yes / No 1 pt
  7. The procedure states when to call the police Yes / No 1 pt
  8. The procedure covers threats received by phone, email or social media Yes / No 1 pt
  9. A lockdown or shelter procedure covers an armed or violent intruder Yes / No 1 pt
  10. Rooms designated for shelter can be locked from the inside Yes / No 1 pt
  11. The front door can be locked quickly from reception Yes / No 1 pt
  12. Visitors and companions are limited in exam rooms when a risk has been flagged Yes / No 1 pt
  13. Appointments for patients flagged as high risk are scheduled when more staff are on duty Yes / No 1 pt
  14. Patients kept waiting past their appointment time are told of the delay by reception before they have to ask Yes / No 1 pt
  15. Security or police non-emergency numbers are posted at reception Yes / No 1 pt
  16. Staff name badges show first name only where company policy allows Yes / No 1 pt
  17. The procedure for restraining orders or domestic violence threats against a staff member is known to the clinic manager Yes / No 1 pt
  18. Clarity of procedures for aggressive behavior Rating
    • Written, known and applied 5 pts
    • Written but not well known 3 pts
    • No written procedures 1 pt

4. Training 16 items

  1. All staff completed workplace violence prevention training in the last 12 months Yes / No 1 pt
  2. New hires complete violence prevention training within the period set by company policy Yes / No 1 pt
  3. Reception and clinical staff were trained in verbal de-escalation Yes / No 1 pt
  4. Training included practice scenarios, not only an online module Yes / No 1 pt
  5. Staff asked could describe two early warning signs of escalating behavior Yes / No 1 pt
  6. Staff asked could describe how to position themselves near the exit Yes / No 1 pt
  7. Staff were trained in the use of the panic devices at this clinic Yes / No 1 pt
  8. Staff were trained in the lockdown procedure Yes / No 1 pt
  9. A lockdown or violent intruder drill was held within the interval set by company policy Yes / No 1 pt
  10. Date of the last lockdown or violent intruder drill Date
  11. Supervisors were trained in supporting staff after an incident Yes / No 1 pt
  12. Contract, temporary and student staff receive the clinic's safety orientation before their first shift Yes / No 1 pt
  13. Training records list the date, the content and the names of those trained Yes / No 1 pt
  14. Staff on the roster Number
  15. Staff with violence prevention training completed in the last 12 months Number
  16. Staff confidence in handling an aggressive patient, from interviews Rating
    • Confident and can describe the steps 5 pts
    • Unsure of some steps 3 pts
    • Do not know what to do 1 pt

5. Incident reporting 17 items

  1. Staff report verbal abuse and threats, not only physical assaults Yes / No 1 pt
  2. An incident report form or system is available at every workstation Yes / No 1 pt
  3. Staff asked know how to file an incident report Yes / No 1 pt
  4. Violent or threatening incidents recorded in the last 12 months Number
  5. Incidents in the last 12 months that caused an injury to staff Number
  6. Date of the most recent incident Date
  7. Each incident sampled was reviewed by the clinic manager within the time set by company policy Yes / No 1 pt
  8. Each incident review records the cause and the corrective action Yes / No 1 pt
  9. Incidents are reported to the workers' compensation or safety authority where local regulation requires it Yes / No 1 pt
  10. Police reports were filed for assaults, with the report number in the record Yes / No 1 pt
  11. Affected staff were offered medical attention after each incident with injury Yes / No 1 pt
  12. Affected staff were offered counseling or the employee assistance program Yes / No 1 pt
  13. A debrief was held with the team after serious incidents Yes / No 1 pt
  14. Incident trends are reviewed by the safety committee or at staff meetings Yes / No 1 pt
  15. Behavior alerts were added to the patient record after incidents sampled Yes / No 1 pt
  16. Staff asked said they can report without fear of blame Yes / No 1 pt
  17. Incident reporting and follow-up Rating
    • Reported, reviewed and acted on 5 pts
    • Reported but follow-up incomplete 3 pts
    • Incidents go unreported 1 pt

6. Lone work 21 items

  1. The clinic schedule avoids having one staff member alone with patients on site Yes / No 1 pt
  2. At least two staff members are present at opening Yes / No 1 pt
  3. At least two staff members are present at closing Yes / No 1 pt
  4. A written procedure covers staff who work alone on site Yes / No 1 pt
  5. Staff working alone check in with a named contact at set intervals Yes / No 1 pt
  6. A missed check-in triggers the escalation steps in the procedure Yes / No 1 pt
  7. The public door is locked when a staff member is alone after hours Yes / No 1 pt
  8. After-hours visitors are identified by intercom or camera before the door is opened Yes / No 1 pt
  9. Staff leave in pairs or are escorted to their vehicles after dark Yes / No 1 pt
  10. Staff making home visits leave their schedule and addresses with the clinic Yes / No 1 pt
  11. Staff making home visits carry a charged mobile phone or a lone worker device Yes / No 1 pt
  12. Home visit risk is assessed before the first visit to a new address Yes / No 1 pt
  13. Staff are permitted to cancel or leave a home visit that feels unsafe Yes / No 1 pt
  14. Cleaning contractors working after hours keep the doors locked Yes / No 1 pt
  15. The bank deposit is not carried by a staff member alone after dark Yes / No 1 pt
  16. Shifts in the last 4 weeks where a staff member worked alone on site Number
  17. Corrective actions from the previous staff safety review have been completed Yes / No 1 pt
  18. Name of the person responsible for staff safety Short text
  19. Name of the clinic manager Short text
  20. Overall protection of clinic staff Rating
    • Layout, alarms, procedures and training all in place 5 pts
    • Measures in place, with gaps in testing, training or follow-up 3 pts
    • No working alarm, or staff do not know what to do 1 pt
  21. Corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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