WeBookCare - Incident Report 
Any incident reported by Health Care Workers or Care Seekers/Recipients that happened during the shift.
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Incident Date *
MM
/
DD
/
YYYY

Incident Time


*
Time
:

Client’s Name

*

Witnessed by/Discovered by

*
Type of Incident *
Required
Description of What Occurred
*
Nature of Injury
*
Location of Incident
*

Immediate Action Taken by Home Healthcare Worker

*
Others Notified
*
Required
Date & Time of notification *
Current Status of Client
*

Immediate Corrective Measures Taken

*

Longer term corrective measures taken - Recommendations to reduce/eliminate future issues

*
Printed Name & Position of Person Completing Report
*
Signature & Date Form Completed
*
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