Safety Questionnaire
Name
Date
Nurse
Time
This questionnaire asks you how safe you feel on the ward.
If staff think that you or someone else is at risk then we may need to tell someone
else
How do you feel about being on the ward?
Why do you feel like this?
Can you speak to staff about this?
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Safety Questionnaire
Tick ( ) if this has happened to you on the ward
Verbal Aggression
This is people saying or shouting horrible things
Physical Aggression
This can people hitting, kicking, throwing things
Intimidation
People trying to scare you or threaten you
Manipulation
People making you do things you don’t want to do
Menacing looks
This is someone staring at you in a horrible way
Ignoring
People being unfriendly to you or not speaking to you
Stealing
People taking or using your things
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Safety Questionnaire
Can you give some more information about this?
Who makes you feel unsafe?
Is there anything else you are worried about?
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Safety Questionnaire
For Staff Use Only
Completion of Questionnaire documented and
uploaded?
Date:
Time:
Discussion with senior nurse/MDT required?
Date:
Time:
Follow up discussion with patient required?
Date:
Time:
Incident form required?
Date:
Time:
LD Team informed?
Date:
Time:
Vulnerable adult Alert raised?
Date:
Time:
Care Plan completed?
Date:
Time:
Action Plan created and implemented?
Date:
Time:
Signature:
Date:
Time:
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Safety Questionnaire