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Professional Incident Accident 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, exact location in home, resident name, and staff witnesses present.
Factual narrative, vital signs, first aid administered, and emergency response.
Time of calls to POA, primary doctor, DSHS/licensing, and ombudsman.
Environmental assessment, prevention steps, care plan updates, and provider signature.
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