Incident Report

Incident / Accident Report

The purpose of this Incident/Accident Report is to construct the factual details of all accidents, incidents or unusual occurrences involving clients or Applicants. It is not an admission of fault or liability. Accidents or incidents involving life-threatening situations need to be reported immediately to Life Foundation Home Care Management. This written report is required within 24 hours of the occurrence. Non-urgent situations require this report be submitted within 5 days of the occurrence.
Client Name*
First Last
Date of Occurance*
MM slash DD slash YYYY
Description of Event*
Description of Actions Taken*
Follow up Required
Suggest any corrective steps that could avoid future occurances
Your Name*
First Last
Today's Date*
MM slash DD slash YYYY
Your Signature