Staff Safety Assessment

Purpose of this form: This form is designed to tap into your experience at the front line of patient care to determine what risks are present in your unit that have jeopardized or could jeopardize patient safety.

Who should us this tool? Health care providers.

How to complete this form: Provide as much detail as possible when answering the two questions below. Drop off your completed assessment in the location designated by the unit team.

When to complete this form: This form can be filled out by any health care provider at any time. At a minimum, health care providers should complete this form semiannually.

Name (optional):
Job category:
Date:
Unit:

Please describe how you think the next patient in your unit or clinical area will be harmed.

Please describe what you think can be done to prevent or minimize this harm.