For providers

Incident report

Something happened during a booking? Write it down here, plainly and promptly, the way you would in a hospital. A PDF copy is created for your records, and a summary goes to the Balay-a team.

If someone is hurt or in immediate danger, call 911 first. File this report after the immediate situation is under control.

1. Who is filing this report

Your details as the provider on the booking.

Your full name

Your phone number

Your email (optional)

Date of this report

2. When and where it happened

Date of incident

Time of incident

Where did it happen?

Client's home Other

Client name

Booking date (if different from incident date)

Client details stay confidential and are handled under our Privacy Policy. We need the name so we can match the report to the right booking.

3. What happened

Check everything that applies.

Fall, witnessed Fall, found afterwards (not witnessed) Responsive behaviour (agitation, aggression, confusion, trying to leave) Client left the home unsupervised Client injury (not from a fall) Provider injury Near miss (no harm, but someone could have been hurt) Medication concern (missed dose or wrong medication noticed) Concern about abuse, neglect, or exploitation Medical emergency (911 called) Property damage Unsafe conditions (clutter, ice, poor lighting) Equipment problem (walker, cane, wheelchair) Missed or very late visit Communication breakdown with the family Other

4. How serious was it

Level of harm

No harm Near miss Minor harm Moderate harm Serious harm

Was 911 called?

Yes No

Was the family or emergency contact notified?

Yes No

5. Describe it

Stick to facts: what happened, in what order, who was there. Write what you saw and did, not what you assume.

What happened

What did you do right away

Witnesses (optional)

6. Follow-up

Should the Balay-a team follow up with you about this report?

Yes No

The PDF downloads to your device for your records. Your email app will then open with the report summary addressed to us. Please attach the downloaded PDF before sending.

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Incident reports are confidential and handled under our Privacy Policy. This form does not replace calling 911 in an emergency.