Sample IHSS Hazard Log for Protective Supervision

Protective supervision is an IHSS service for recipients who require 24/7 supervision to prevent injury to themselves or others due to "severely impaired judgment, orientation, and/or memory." It may be useful to provide your doctor with a log of your child’s potentially hazardous behavior in terms of judgment, orientation, and/or memory so they have a sense of how to fill out the SOC 821 form required for IHSS protective supervision.

You can review this Google doc as reference when you create your log, or make a copy and add data on your own child.