EmailMe Form - Incident/ Accident Report

HISC Person making this Incident Report *

Email *

add your email

KEY PEOPLE ****************************

KEY PEOPLE & DATES

Date Incident was reported to the office *

MM / DD / YYYY

Person Calling to report Incident to the office *

Date/ Time Incident took place *

MM / DD / YYYY HH : MM AM/PM

Person from Agency office who took the call *

Name of Client(s) involved *

Name of Caregiver(s) on duty (if applicable) *

Copy and paste to Angie and Rosa

(*) Angie/ Rosa - I am doing an incident report for [Name of CG] for [date] with [Name of client]

Angie - pls confirm CG on HCR for that date
Rosa - pls confirm Time and Activity report status for that date

Date this report was made *

MM / DD / YYYY

Make sure it is within 24 hours of the incident taking place (if possible)

KEY FACTS****************************

KEY FACTS

Exact location of the Incident: *

Exact time of day the incident took place *

Names of all parties who witnessed the incident
1. Name
2. Phone #, Email
3. Relationship of this party to Patient, to HISC Agency *

This info for all witnesses to the incident

Description of the Incident: *

(*) Copy and paste

At [time and place] the following took place [detail]

Once agency was notified, the following actions were taken by the agency

(*) Agency staff immediately called all parties to verify facts

(*) [Add details of some actions taken to show we actively called and/or virtual visit or in person visit etc]

(*) The following medical interventions were taken: [write NONE if none were taken or describe if 911 was called or if client was taken to urgent care etc]

(*) The following were informed of the incident: [list who we at HISC contact in terms of HCP, NOK, MDs]

Pictures / Files if available:

Be careful with this since this can hurt us. Only if they help please add

Please upload available image, audio or video from your computer. Files must be pdf, jpg, jpeg, png, mp3, mp4 or avi.

Outcome / Follow-up *

(*) Copy and paste

As a result of the incident,

(*) Outcome (Patient Status) so far is that patient is currently [mention where the client is, how the client is doing , etc]

(*) The following followup recommendations were made [describe which recommendations and by whom]

HISC Rep Name Signature *

Clear

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