Documentation Tool

Protective Supervision
Hazard & Injury Log

A documentation tool for IHSS providers in California to record non-self-directing behaviors, near-miss incidents, and accidents involving a recipient who cannot cognitively assess danger or risk of harm.

Recipient Name

Date of Birth

IHSS Case Number

County

Provider Name

Relationship to Recipient

Log Period — Start Date

Log Period — End Date

How to Use This Log

1
Review the behavior reference list. The reference list shows common non-self-directing behaviors. Identify which ones apply to the recipient.
2
Log every incident. Include both observed and attempted behaviors, with date, time, and a clear description. Near-misses count.
3
Sign and date the declaration. Your signature is a sworn declaration that the entries are accurate.
4
Use it year after year. During the initial application process and then year after year for every reassessment.

What Strengthens Your Case

Frequency matters. Counties look for behaviors that occur regularly and unpredictably. A behavior happening twice a week may not be enough; show how often supervision is required.
Document attempted behaviors. Per California ACL 15-25, a recipient does not need to suffer actual injury. Behaviors you prevented through intervention still demonstrate the need for Protective Supervision.
Be specific. Vague entries like "wandered" are weaker than "tried to unlock the front door at 2:14 AM while the household slept; redirected back to bed." Time, location, and detail strengthen the record.
Stay consistent across documents. The behaviors in this log should match what is described in the SOC 821, IEP, Regional Center IPP, and any medical or psychological reports.

Reference List of Non-Self-Directing Behaviors

Section 1

Important This list is not exhaustive. It identifies common categories of dangerous behaviors associated with cognitive impairment, mental impairment, or mental illness. Document any incident in Section 2, including attempted or prevented behaviors. Per California ACL 15-25, a recipient does not need to suffer actual injury to qualify for Protective Supervision; a propensity for placing oneself in danger is sufficient.

Counties evaluate each behavior individually. Documentation strengthens but does not guarantee approval. Consult an experienced Protective Supervision attorney or advocate for case-specific guidance.

Wandering & Elopement

Wanders out of the home and gets lost
Bolts or runs from caregiver in public
Runs into the street without regard for traffic
Leaves the home at night while others sleep
Climbs out of windows
Unlocks doors and exits unsupervised
Wanders away from school or supervised setting

Kitchen & Fire Hazards

Turns on stove or oven and leaves unattended
Lights matches, lighters, or candles
Leaves lit cigarettes around the home
Microwaves unsafe items (metal, non-food)
Uses knives or sharp objects unsafely
Forgets food cooking on the stove

Water Hazards

Leaves water running in sink or tub
Turns water to scalding temperatures
Floods the bathroom or kitchen
Enters pool or water without ability to swim
Plays with toilet bowl water

Electrical Hazards

Inserts fingers or objects into outlets
Puts plugged cords or chargers in mouth
Tampers with light sockets or appliances
Plays with exposed wires

Self-Injurious Behaviors

Document only when these behaviors occur due to cognitive impairment. Avoid wording like "when frustrated" or "when upset" which counties may interpret as intentional or self-directing.

Headbanging on floors, walls, or furniture
Self-biting, hitting, or slapping
Scratching skin until bleeding
Picking at open wounds, sores, or scabs
Hair pulling
Climbs to high places and jumps off

Eating & Ingestion

Eats non-food items / pica (dirt, soap, paper)
Eats food from trash
Eats spoiled or unsafe food
Drinks unsafe liquids (cleaners, bleach)
Chokes due to overstuffing or improper chewing

Falls & Physical Danger

Climbs furniture, counters, or shelves
Falls due to lack of awareness of physical limits
Runs in unsafe areas (stairs, slick floors)
Hides in dangerous spots (refrigerator, dryer, closets)

Stranger & Social Danger

Counties give more weight to behaviors that occur in the home. Document community incidents alongside in-home behaviors when possible.

Lets strangers into the home
Walks off with unfamiliar people
Shares personal information with strangers

Nighttime Behaviors

Wakes during the night and wanders the home
Attempts to leave the home at night
Engages in unsafe activity while others sleep

Medication & Chemicals

Accesses medications without supervision
Ingests cleaning products or chemicals
Uses unsafe products to bathe or clean self

Hygiene & Bodily Behaviors

Plays with feces or smears
Forgets safety routines (handwashing, etc.)
Removes clothing in unsafe situations

Other Cognitive Hazards

Forgets people, places, or recent events
Becomes disoriented to time or surroundings
Cannot follow basic safety instructions
Mixes up day and night routines

Incident Log

Section 2

Record each observed or attempted incident below. Include near-misses and behaviors that were prevented by your intervention. Specific dates, times, and descriptions strengthen documentation. Add as many entries as needed.

How to save your progress: Click Save Progress to download a copy of this file with all your entries. Reopen that file later to keep working. To start a new annual log, download a fresh blank copy from ihssunlocked.com.

Print tip: In the print dialog, open More settings and uncheck Headers and footers for a clean output without URL or timestamp.

Provider Declaration

Section 3

I declare under penalty of perjury under the laws of the State of California that the incidents recorded in this log are true and accurate to the best of my knowledge, and that they reflect actual or attempted behaviors observed during the period stated above.

Provider Signature

Date