Home-Incident/Accident Report Client Company : Employee : Department Email Date and Time Reported : Date of Incident :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of Incident : HH MM AM PM AM/PM 1. Type of Incident Slip/Fall Cut/Puncture Wound Chemical Spill Occupational Exposure Vehicle Other Was medical care required? Yes No Incident reported by : DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920The Employee’s description of the Incident /Accident is: (Must be hand-written by injured employee - use separate sheet ifnecessary-be specific as to the body part that is injured)2.VEHICLE accident: Complete this form, Vehicle Accident Report Form and attach a copy of the police report, if available.3. If OCCUPATIONAL EXPOSURE, complete the following: Type of Device(s) Brand Size of device Procedure being performed What step in procedure did injury occur? Testing done on Source Patient Yes No Results of Source Patient’s Tests : Known to be positive for : HBV HVC HIV None Waiting on Result Employee was counseled for Post-Exposure Prophylaxis (PEP) & given written information accordingly: Yes No PLEASE CHECK one of the following: Employee requests post-exposure medical evaluation Employee has refused post-exposure medical evaluation (must sign Informed Refusal of Post Exposure Medical Evaluation) Employee does not want testing at this time, but requests to draw and store blood for possible testing within the next 90 days. Detailed description of any first aid given at time of occurrence :I AGREE TO THE INFORMATION AS DESCRIBED ABOVE : YES NO If no, please comment :EMPLOYEE COUNSELINGDate counseled :Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Counseled by : Recommendations (possible measures to be taken to avoid similar incident or accident)WITNESS(ES) OF THE INCIDENT/ACCIDENTName : Work # : Mobile # :Name : Work # : Mobile # :Manager Signature Supervisor Signature Caregiver Signature CAPTCHA
