Client Name *

Date of Incident: *

Time of Incident: *

Location of Incident: *

Employee(s) Involved: *

Witness(es): *

If "other" was selected, describe: *

Detailed Description (objective facts only): *

Action Taken: *

Was 911 caled? *

Yes
No

Was Supervisor Notified? *

Yes
No

Who was the supervisor notified? *

Client's condition after the incident *

Employee's Name *

Date *

Beyond the ordinary

At Class Home Care, LLC, safety is more than a policy — it is part of our commitment to delivering high-quality care with dignity, compassion, and professionalism.