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HOME
About Us
Client Intake
Join Us
Report An Incident
Progress Notes
Request Forms
Download Forms
- Participant Documents
- Policy Form
Upload Forms

Incident Report Form

This form is to be used for reporting incidents, in accordance with the Incident Management Policy which you can read here.
If you are reporting on a reportable incident, or are not sure whether this may be a reportable incident, please immediately contact the incident manager or other key personnel.
Part A- To be completed by a worker who has become aware or witnessed the incident.

Part A

Incident Report Details

Details of Worker who incident was first reported to:

Name: *

Position: *

Contact Details:

Has this incident been reported to the Incident Manager? *YesNo

Name of the NDIS Participant affected by the incident

Title: *

Surname: *

Given Name(s): *

Address: *

Phone: *

Date of Birth *

Email Address *

Next of Kin: *

Surname: *

Given Name:

Incident (select applicable) *Acts, omissions, events occurring in relation to providing supportsHave or could have caused harmActs by person with a disabilityHave caused serious harm or risk of harm to another

Incident Details

Date of, or disclosure of, event: *

Time

Location: *

Type of incident

Please tick the most relevant type of incident from list below: *Incident that resulted in harm or risk of harm to a ParticipantIncident caused by a Participant resulting in serious harm or risk of serious harm to another person

Reportable Incidents: *Death of a ParticipantSerious injury to a ParticipantAbuse of neglect of a ParticipantUnlawful physical contact or assault of a ParticipantUnlawful sexual contact with or sexual assault of a ParticipantSexual misconduct committed against or in presence of a ParticipantUse of an unauthorised restrictive practice in relation to a Participant

Non- NDIS/Other incident: *Work Health & safety incidenInfectionHazardous ExposureChild SafetyOther

Describe the incident *

Is this a reportable incident? *YesNo

Is this an incident regarding child safety? *YesNo

If yes, has the Incident Manager been notified? *YesNo

(For Injuries) – Nature of Injury *Contusion/crushBurnDislocationAmputationLaceration/open woundSuperficial injuryForeign bodyInternal InjuryConcussionSprain/strainFractureDermatitis

(For Injuries) – Location of Injury *Head/faceEyeInternal organsHand/fingersShoulder/armsTrunk (other than back)Hip/legFoot/toesBackOther

Immediate actions taken to make situation safe (including any medical treatment received, or assistance provided/offered): *

Witnesses (for Notifiable incident attach signed witness statement or letters of complaint)

Witness Name:

Witness Phone Num:

Email Address:

Part B

INVESTIGATION - to be completed by Incident Manager and/ or other Key Personnel
Always ensure the person/s affected by the incident are considered during the investigation

Outcome of Investigation: *

(For Reportable Incidents) Reported incident to NDIS? *YesNo

Date of contact: *

(For Child Safety Incidents) Reported incident to Child Safety’s local regional intake service or Child Safety Service Centre? *YesNo

List Service Centre and date of contact: *

Reported incident to any other external agencies? *YesNo

List Agency and Date of contact please

Please note: NDIS reportable incidents must be reported to the NDIS Quality & Safeguards Commission within 24 hours, except in the case of an unauthorised restrictive practice where no harm or injury has resulted which must be reported in 5 days.

Action/s to be taken to prevent further similar incidents from reoccurring or minimise their impact:

Action:

Responsibility:

Completion Date:

Have all relevant parties been spoken to and consulted? *

Was the incident preventable? *

How well was the incident managed? *

How well was the incident resolved? *

Do other parties/ external agencies need to be notified of the outcome? *

Has Participant been consulted and feedback sought regarding: *How well the incident was managedWhether they received adequate supportExpectations for appropriate resolutionUpdated on the investigation/ outcomes/ findingsInformed of actions taken

Feedback From Participant *

Incident Discussed at Team Meeting? *

Investigator Details

Name: *

Signature: *

Incident Manager Signature *

Completed form to be stored and Incident to be recorded in Incident Management Register

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Address

AMP Building, Level 10, 1 Hobart Place Canberra City ACT 2600 Main house in Macquarie, ACT 2614

PO Box: 4253 Ainslie ACT 2602

Contact Info

Phone: 0450 440 408
Email: info@enableilhss.com.au

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