GSHomeCare Injury Report

Greenstaff HomeCare Care Partner Injury Report
Pleae select if you are a Supervisor or Care Partner
Care Partner Injury Report
Care Partner Name:
Date of Report:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Injury:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Injury

Hour Minutes

AM/PM Option
Client Name ( if applicable )
Location of incident
Describe the incident in your own words
(Explain what happened immediately before, during, and after the injury.)
What task were you performing at the time?
How did the injury occur?
(Be specific: lifting, fall, strain, slip, client behavior, equipment failure, etc.)
What part of your body was injured?
Did anyone witness the incident?
Did you report the injury immediately?
If NO, explain why
Immediate symptoms or pain level (0–10)
Did you seek medical attention?
Where did you go for treatment?
Please explain why. Do you plan to seek treatment at a later date
Were you able to continue your shift?
Additional details you feel are important
I confirm that this injury report was completed accurately and promptly after the injury occurred, and I can confirm the information stated above is correct
Signature
Location
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Supervisor Incident Report
Supervior Name

First NameLast Name
Date completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Care Partner Name

First NameLast Name
Client Name ( if applicable )

First NameLast Name
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident

Hour Minutes

AM/PM Option
Exact Location Where the Incident Occurred
Summary of Care Partner’s account of events
(Brief recap — attach CP form as supporting document.)
Summary of Client’s or Witness’ account (if applicable)
Task being performed at time of incident
Supervisor assessment of how the incident occurred
(Identify contributing factors such as environment, equipment, unsafe action, etc.)
Was the area assessed for hazards?
Findings
Was proper procedure followed?
If NO, please explain
Immediate actions taken
If OTHER was selected, please explain
Supervisor recommendation to prevent recurrence
Please describe your selection
Injury Filing Requirements
Both CP & Supervisor form received and submitted to HRworkerscomp@greenstaffhomecare.com
First Report of Injury filed with carrier
Injury added to tracker
Employee's Signature
Location
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Greenstaff HomeCare Care Partner Injury Report

Care Partner Injury Report

Supervisor Incident Report