Policy Manual sample

MDT Home Health Care Agency, Inc. EMPLOYEE ACCIDENT/INCIDENT REPORT Employee’s Name: ____________________________________________________________ Employee’s No.: ________ Diagnoses: ___________________________________________ Address: ____________________________________ _____________________________________ Phone: _________________________ City: _______________________ State: _______________ Zip: _____________ Physician’s Name________________________________ Phone: ______________________ Personnel Involved: __ RN __ L.P.N. __ S.T. __ HHA __ PT __ S.W. __ OT Accident Reported By: ________________________________________ Reported To: ________________________________________________ Narrative: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Supervisor Notified: __ Yes __ No, Name:__________________________________________ Action Taken: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Doctor Notified: __ Yes __ No, By Whom: __________________________________________ Date of Call: _______________________ Action Taken: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Remarks: ___________________________________________________________________________ ___________________________________________________________________________ Home Health Agency. - - Personnel/Operations Policies B-68