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Professional Employee Injury Report template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base 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.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Date, time, location, body part injured, and detailed narrative of work injury.
Witness names, statements, and medical treatment provided on scene.
Safety hazard investigation, equipment check, and prevention measures.
L&I / Workers Comp claim number, clinic visit log, and return-to-work status.
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