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Incident Report
This form is used to capture details of incidents/accidents that occur while working for Hendlee Home Care
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* Indicates required question
Email
*
Your email
Name of Person Reporting Incident
*
Your answer
Identity of person making the report
*
Caregiver
Client
Family member
Other
Persons involved
*
Client
Caregiver
Other
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Location of incident (i.e., address, room, etc.)
Your answer
Incident Type
*
Choose
Fall
Personal injury
Inappropriate behavior
Medical emergency
Property harm, theft, or loss
Threats or Intimidation
Assault
Drug/alcohol
Sexual abuse/exploitation/harrasment
Other
Provide description of incident (explain what happened, why, how)
*
Your answer
What body parts were injured?
Your answer
Was first aid administered?
Yes
No
Clear selection
Who administered first aid?
Your answer
Was the injured person taken to the hospital?
Yes
No
Clear selection
Name of hospital injured was taken to?
Your answer
Was emergency contact notified?
Yes
No
Clear selection
Send me a copy of my responses.
Submit
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