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(VRF-UKKP Bil. 2/2023)

BORANG SIASATAN INSIDEN KEKERASAN

VIOLENT INCIDENT INVESTIGATION FORM
*Borang Perlu Dihantar Kepada: UKKP (Program Perubatan)/ KPAS (Kesihatan Awam) di JKN
Jabatan Kesihatan Negeri
UKKP (Program Perubatan)/ KPAS
1. DATA PERIBADI/PERSONAL INFORMATION
Jabatan Kesihatan Negeri
Nama/Name: ……………………………………………….
No. Kad
Pengenalan:
ID NUMBER

Jawatan/Job Title Designation / Grade : ………………………………………………..

Jabatan/Department: ……………………………………………….
Tempoh Perkhidmatan/Years in service : ………………………

2. PERINCIAN
Hospital : KEJADIAN/DETAILS OF INCIDENT
Tarikh & Masa Kejadian/Date & Time of Incident: ………………………………….
Hospital/Institution:

Lokasi Kejadian/Location of Incident: ……………………………………….

Pelaku/
Assailant(s): Pesakit (Patient) Pelawat (Visitor)
Waris Pesakit/Ibu Bapa/Penjaga Lain-lain (Others)
(Patient’s relatives/Parents/ ……………………………
Guardian)

Saksi-saksi (jika ada):

Witness(es)(if any):

No. Name Phone Number

1.
2.
3.

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Pada pandangan anda, kejadian yang melibatkan kekerasan ini boleh dikategorikan
sebagai… (anda boleh tandakan lebih daripada satu kotak jika perlu):
In your best professional judgement, this incident involving violence can be best
categorized as (tick more than one box if necessary):

Kekerasan fizikal / Physical assault Kerosakan harta/ Property damage

Vandalisma/Vandalism
Kekerasan lisan/ Verbal threat
Serangan seksual/Sexual harassment
Ancaman bertulis/Written threat
(Surat/media sosial/sms)
o Fizikal
(letter /social media / sms)
o Verbal
o Bertulis

Lain-lain (mohon perincian):

Others (please specify):

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Perincian kejadian (tambah lampiran jika perlu)

Specifics of incident (Attach another page if necessary):
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3. TINDAKAN YANG TELAH DIAMBIL

3.1 Pengaktifan Kod Grey:

Ya/ Yes Tidak / No
Activation of code grey :

Jika YA, sebab pengaktifan code gey?

If YES, the reasons for activation of code grey?
…………………………………………………………………………………………
3.2 Adakah mangsa cedera?/
Ya/ Yes Tidak / No
Did the victim hurt?
Jika YA, kecederaan yang dialami?
If YES, the injury sustained?
…………………………………………………………………………………………

3.3 Adakah mangsa diberi Ya/ Yes Tidak / No

rawatan?/
Did the victim treated?
Jika YA, rawatan yang telah diberi?
If YES, treatment given?

…………………………………………………………………………………………

3.4 Bilangan hari cuti sakit / Days of MC leave given:

3.5 Adakah mangsa diberi rawatan

debriefing?/ Ya/ Yes Tidak / No
De-briefing done to the victim?
Jika YA, siapa yang melaksanakan debriefing ini? If YES, who did the debriefing?
………………………………………………………………………………………

3.6 Markah DASS/ DASS Score:

3.7 Adakah mangsa dirujuk

kepada kaunselor?/ Victim Ya/ Yes Tidak / No
referred to the counselor?

3.8 Adakah mangsa dirujuk

kepada pakar psikiatri?/ Need Ya/ Yes Tidak / No
psychiatric intervention and
evaluation?

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3.9 Laporan polis dibuat/

Police report made : Ya/ Yes Tidak / No

Jika YA, tarikh laporan polis?

If YES, Date of police report?
…………………………………………………………………………………………
No Laporan / No Report:

Jika TIDAK, Mengapa/ If NO, Why?

…………………………………………………………………………………………

3.10 Status kes/ Case status: Belum diambil tindakan /

No action has been taken

Dalam siasatan /
Under investigation

Selesai / Completed

4. NOTIFIKASI DAN PENCEGAHAN

Tarikh & masa notifikasi diterima/Date & time of notification form received:

Apa penyebab kejadian kekerasan ini? (Senaraikan sebarang keadaan yang bahaya,
perlakuan-perlakuan atau prosedur-prosedur didalam sebarang bentuk yang menyumbang
kepada kejadian kekerasan):

What caused this violent incident? (List any unsafe conditions, acts or procedures that in any
manner contributed to the violent incident.):
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Ulasan/Comments:

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PELAN TINDAKAN/ACTION PLAN:

(Kenal pasti sebarang tindakan pembetulan yang telah diambil dan sebarang cadangan
tindakan untuk mengelakkan kejadian serupa) (Identify any corrective actions that have
been taken and any recommended actions to prevent similar incidents.)

Ulasan/Comments:

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Pegawai Yang Melakukan Siasatan /Persons Conducting Investigation:

Nama/Name Jawatan/ Tandatangan & Cop

Designation Rasmi / Signatire &
Official Stamp

Ulasan Penyelia / Ketua Jabatan:

Supervisor / HOD comments:

Ulasan Pengarah Hospital/ PKD /Hospital Director/ DHO comments:

Nama dan tandatangan Pengarah Hospital/ PKD:

Hospital
Nama danDirector/ DHO Ketua
tandatangan name and signature:
Jabatan/
Head of Department name and signature:

…………………………………………………………………

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