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Incident Report Form
This form is used to document a Care Pro or Client incident.
If you are injured or feel unsafe, call 911 for immediate assistance.
If you cannot work your next shift, per policy, you must call 509-591-0019 and speak with someone from the office.
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* Indicates required question
Name of Person Reporting Incident (First and Last)
*
Please provide your first and last name:
Your answer
Person or People Involved in Incident (mark all that apply)
*
CAREGiver
Client
Client's Family Member
Other:
Required
Mark Your Role
*
CAREGiver
Client
Client's Family Member
Other:
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