Incident Report Form
Incident Report Number
Incident Details
Full Name
Gender
Male
Female
Date of Birth
Phone Number
Role of Person Involved
Worker
Participant
Participant’s family
Others
Date of Incident
Time of Incident
Location of Incident
Witnesses
Witness 1 Name
Witness 1 Phone
Witness 1 Address
Witness 2 Name
Witness 2 Phone
Witness 2 Address
Description of Incident
Incident Description
Type of Incident
The Death
Medication error
Injury/illness/medical concern
Detected waste, infectious or hazardous substances
Violence, abuse, neglect, exploitation & discrimination
Property damage
Unlawful sexual or physical contact with, or assault
Equipment failure
Sexual misconduct
Motor vehicle accident
Behaviours of concern
Absconding
The unauthorised use of restrictive practice in relation to an NDIS participant
Others
Injury Details
Part of body injured (draw below):
Clear
Mechanism of Injury
Falls/trips/slips
Hitting objects with part of the body
Hit by moving objects
Sound/pressure
Body stress/manual handling
Heat/electricity
Chemicals/other substances
Biological factors
Mental stress
Vehicle incident
Nature of Injury
Head/intracranial
Burns
Strain/pain
Fractures
Injury to spinal cord
Electrocution
Laceration/amputation
Joint/ligament damage
Diseases/conditions detail
Internal organ damage
Foreign body
Notification
Reportable Incident?
Yes
No
NDIS Commission notified?
Yes
No
Immediate notification?
Yes
No
5 Day notification?
Yes
No
Date of notification:
Does this incident require to notify other parties (e.g. notifying family/guardian if the participant is a child)?
Yes
No
Does this incident require to notify police (e.g. crime, etc.)?
Yes
No
Does the severity of this incident require notification to Safe Work?
Yes
No
Date of notification:
Treatment
Medically treated?
Yes
No
If yes?
First aid
Medical centre
Hospital (Admission)
Lost Time Injury (LTI)?
Yes
No
Days lost:
Details of Action Taken
Sign Off
Report completed by:
Date:
Signature
Clear
Investigation
Preliminary findings
Root causes analysis
Did the incident occur as part of the involved person’s normal activities?
Yes
No
N/A
Did equipment contribute?
Yes
No
N/A
Was the equipment used designed for activity?
Yes
No
N/A
Was the equipment properly maintained?
Yes
No
N/A
Did the equipment fail?
Yes
No
N/A
Had a risk assessment been undertaken?
Yes
No
N/A
Did safety instructions accompany activity?
Yes
No
N/A
Are there documented safe work procedures (SWP) for activity?
Yes
No
N/A
Were these SWP followed?
Yes
No
N/A
Was appropriate PPE used?
Yes
No
N/A
Was the involved person trained in this activity?
Yes
No
N/A
Did a known behaviour problem contribute?
Yes
No
N/A
Was there a known behaviour management plan?
Yes
No
N/A
Was it followed?
Yes
No
N/A
Did poor housekeeping contribute?
Yes
No
N/A
Did the work environment contribute?
Yes
No
N/A
Others
Corrective actions
Description of actions:
Responsible:
Position:
Deadline
Comments by director
Findings:
Completed on:
Status:
Open
More action required
Closed effectively
Outcomes::
Run training/induction session
Review/amend relevant process/documents
Review/update risk register
Create a new procedure
Others:
Completion checklist:
Incident details fully completed by the worker/person involved?
Relevant Manager completed and signed?
Incident register completed?
If Property damage, maintenance request completed?
Did the director complete and signed?
Is feedback given to participant/worker and others involved?
Sign Off
Investigation completed by:
Date:
Signature
Clear
Acknowledgement
I, ________________ (Participant / Participant’s representative/ Worker) subject to this incident report have been engaged and informed with the detail of the investigation and I am satisfied with the with the outcome, I have received a copy of this report.
Name:
Date:
Signature
Clear
