Rating Score Risk Category Identified Risk(s) and Intervention(s) (Highlight One) Emergency Agency Moderate HIGH Contact Numbers: Moderate HIGH Agency On-Call Number: Moderate HIGH Moderate HIGH Supervisor Number: Moderate HIGH Moderate HIGH Moderate HIGH Moderate HIGH Recent Photo Name: This form is a summary of information from the IISP and should be accessible in hard copy to staff in order to promote awareness of risk which require ongoing caution / action of Agency Plan / Personal Support Plan Date revised: the staff. Considering likelihood and severity, the form includes risks that present immediate life threatening danger to the client or others. This form can be edited and modified to capture and convey the information in a usable format. Note: This form is not necessary if the IISP Template is used since the template includes a risk summary on page 1 Completed by: Signature:
Recent Photo Name: Date revised: This form is a summary of information from the IISP and should be accessible in hard copy to staff in order to promote awareness of risk which require ongoing caution / action of the staff. Considering likelihood and severity, the form includes risks that present immediate life threatening danger to the client or others. This form can be edited and modified to capture and convey the information in a usable format. Note: This form is not necessary if the IISP Template is used since the template includes a risk summary on page 1 Rating (Highlight One) Score Risk Category Identified Risk(s) and Intervention(s) Moderate HIGH Emergency Agency Contact Numbers: Moderate HIGH Moderate HIGH Agency On-Call Number: Moderate HIGH Moderate HIGH Supervisor Number: Moderate HIGH Moderate HIGH Moderate HIGH Agency Plan / Personal Support Plan Completed by: Signature: