An editable Caregiver Illness and Exposure Incident Report form for non-medical home care agencies.

For supervisors and office staff who need a consistent way to record when a caregiver reports symptoms or a possible exposure.

What’s included (5 pages; editable Word .docx):

• Pages 1-4: Part A report details; Part B illness (symptoms only); Part C exposure, with C1 blood or other body fluid exposure and C2 close contact with a contagious illness; employee statement; Part D supervisor review and actions; Part E filing
• Marked confidential, with a note to keep it apart from the personnel file
• Page 5: Agency Instructions page (remove before use)

How to customize:

1. Open the Word file and use Home > Replace > Replace All to change [Agency Name] to your agency’s name.
2. Replace [City] and [State] in the letterhead the same way; [Agency Name] also sits in the gray page header from page 2 on, so check it there.
3. Fill each [State] spot and set the agency-defined values (for example, contact and reporting steps) before staff use it.
4. Add your logo to the letterhead if you want one (there is no logo box), then delete the final Agency Instructions page before use.

Some lines cross-reference policy numbers from a companion Policy & Procedure Manual (sold separately); edit them to match your own policies.

A form for recording what happened; it is not medical advice or a clinical record.

Customizable template, not legal advice; check your state’s requirements. Not a license to operate, not HIPAA software, and no medical claims. It is not a clinical protocol, it is not a certification, and it does not promise that you meet any law or standard; review it against current public health guidance and your state’s rules before use.