Mental Health Transport Risk Assessment Form (Page 2 of 2) in pdf

Mental Health Transport Risk Assessment Form Page 2

RISK ASSESSMENT NOTES This section has been provided to record notes relevant to the risk assessment.

RISK ASSESSMENT NOTES

Details such as next of kin/trusted friend, location of crisis, consumers behaviour and/or demeanour, current

or history of mental illness/treatment, severity of situation and agency response can be recorded here.

Risk Summary:

Transport risk issue:

Medical risk that may impact on safe escort

(e.g. heart condition, epilepsy)

Sensory impairment

(e.g. sight, hearing, intoxication):

Access to weapons, concealed or otherwise:

Delusional systems that may impact on safe escort

(e.g. fear of authority figures):

All STAFF INVOLVED IN TRANSPORTATION ARE REQUIRED TO UTILISE UNIVERSAL PRECAUTIONS TO AMELIORATE THE RISK

OF INFECTIOUS DISEASES

SECTION 4

–

RESULT OF ASSESSMENT

SECTION 4

–

RESULT OF ASSESSMENT

Having conducted a risk assessment in relation to the request for transport assistance, it has been determined

that:

FORM 4A SIGNED

POLICE ARE REQUIRED

POLICE ARE NOT REQUIRED

Please circle risk level

SIGNATURE:______________________DATE:_______/_______/_______TIME:__________________HRS

Mental Health Transport Risk Assessment Form Page 2