The Johns Hopkins University | Safe at Hopkins

The Johns Hopkins University | Safe at Hopkins | www.safeathopkins.org

Safe at Hopkins
www.safeathopkins.org

Risk Assessment Team Intake Form
To Be Completed by the RA Team Member Accepting a Referral

INSTRUCTIONS:

1) Please complete a RAT Intake Form whenever a call is received regarding a potential Risk Assessment event/situation.
2) While speaking with the caller, gather as much information as possible to facilitate efficient communication between the RATeam.
3) Type your responses in the spaces provided below.
4) Using your web browser's "Print" function, print out the completed form.
5) Fax the completed form to FASAP at 410-955-4623, and to other RATeam members requesting the information.
6) Email a brief but detailed description of the event to the RATeam (with cc: to management), as per RATeam protocol.

Date of Call:	/ /
Call Received by:

Caller's Information:

Name of Caller:

Job Title:

Phone & Pager #:

Department/Worksite:

Relationship to Employees Involved:

Information about Employees Involved:

Name of Employee #1:

Social Security #:

Home & Work Phone #:

Job Title:

Is he/she a Union Employee?

Institutional Affiliation (select one):

Supervisor(s) Name & Phone #:

Name of Employee #2:

Social Security #:

Home & Work Phone #:

Job Title:

Is he/she a Union Employee?

Institutional Affiliation (select one):

Supervisor(s) Name & Phone #:

Name of Employee #3:

Social Security #:

Home & Work Phone #:

Job Title:

Is he/she a Union Employee?

Institutional Affiliation (select one):

Supervisor(s) Name & Phone #:

Name of Employee #4:

Social Security #:

Home & Work Phone #:

Job Title:

Is he/she a Union Employee?

Institutional Affiliation (select one):

Supervisor(s) Name & Phone #:

Were any Non-Employees Involved: NOYES

RATeam Members Involved (if known):

HR Representative(s):

FASAP Clinician(s):

Security:

General Counsel:

Other:

Date RATeam Notified by E-Mail: / /

Anticipated RAT Meeting Date: / /

After completing this form, please print it out and fax it to FASAP at 410-955-4623.
After faxing this form, email the RATeam and involved management with a brief but detailed description of the event.

View the Risk Assessment Flowchart

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