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SAFETY & FOLLOW-UP
Document the details.Support clear communication and timely follow-up.
ALLIANCE HOME HEALTHCARE
Purpose: To document any accident, injury, or incident involving a client, caregiver, or visitor during service delivery. This form supports timely follow-up, risk mitigation, and compliance.
General Information
Date of Incident *
Time of Incident *
Location of Incident *
Client Name *
Caregiver Name *
Other Individuals Involved (if any)
Type of Incident
Check all that apply Client InjuryCaregiver Injury
Witness Information
Witness Name
Immediate Actions Taken Calling Emergency ServicesContacting on-supervisorUpdate client's emergency contact
Description of Incident
Provide a clear, factual account of what happened
Signatures
Staff Name Completing Form *
Date Completed *
Signature (Type Full Name as Digital Signature)
