Employee Injury Report
Professional Employee Injury Report template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Employee Injury Report
TEMPLATE • Inspection-Ready AFH Standard
1. Employee Incident Report & Injury Description
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Witness Statements & Immediate First Aid Administered
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. Supervisor Root Cause Analysis & Corrective Action
Provider Signature / Date
Resident / POA Signature / Date
Purchase to Unlock Full Document
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Document Section Breakdown (4 Sections)
Employee Incident Report & Injury Description
Date, time, location, body part injured, and detailed narrative of work injury.
Witness Statements & Immediate First Aid Administered
Witness names, statements, and medical treatment provided on scene.
Supervisor Root Cause Analysis & Corrective Action
Safety hazard investigation, equipment check, and prevention measures.
Workers Compensation Claim Filing Verification
L&I / Workers Comp claim number, clinic visit log, and return-to-work status.
Or get this form included in the Operations & Records Bundle ($69)