Incident Accident Report
Professional Incident Accident Report template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Incident Accident Report
TEMPLATE • Inspection-Ready AFH Standard
1. Incident Details & Location Log
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Description of Event & Immediate Care Given
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. Family, Physician & State Notification Log
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (4 Sections)
Incident Details & Location Log
Date, time, exact location in home, resident name, and staff witnesses present.
Description of Event & Immediate Care Given
Factual narrative, vital signs, first aid administered, and emergency response.
Family, Physician & State Notification Log
Time of calls to POA, primary doctor, DSHS/licensing, and ombudsman.
Root Cause Analysis & Corrective Action Plan
Environmental assessment, prevention steps, care plan updates, and provider signature.
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