Incident Report Form NEW Incident Report Form Contact Details of Person Reporting the IncidentNameIncident DatePosition / RelationshipIncident Start TimeContact DetailsIncident End TimeIncident LocationIncident Register Number (Administration Only) Person (s) Impacted by Incident / Injury Name Participant/Public/Worker Contact Details Gender Service Select OneParticipantPublicWorker FemaleMaleOther Save & Resume Type of IncidentType of Incident Verbal threat to a participant Fire Explosion Verbal threat to support worker Physical assault of a support worker Physical assault of a participant Participant whereabouts unknown Alleged harm or potential harm of a participant Emergency Services attended Minor injury to participant Threat with an object/weapon Vehicle/car accident Incorrect medication taken Assault with an object/weapon Electrocution Incorrect medication dosage Participant self-harming Property damage Incorrect recording of medication Dangerous behaviour in a vehicle Any violation of human rights, abuse, harm or neglect of a participant – Complete Reporting Abuse, Neglect and Exploitation Form Medication not taken Seizure Injury to worker member (Report to Directors) Any other dangerous or potentially dangerous event not listed above OtherOtherNDIS Reportable IncidentsNDIS Reportable Incidents The death of a participant Serious injury of a participant (fractures, burns, deep cuts, extensive bruising, head or brain injuries, or any other injury requiring hospitalisation) Abuse or neglect of a participant (physical, psychological, or emotional, financial, systemic abuse) Unlawful sexual or physical contact with, or assault of a participant (excluding, in the case of unlawful physical assault, contact with, and impact on, the person that is negligible) Sexual misconduct committed against, or in the presence of a participant, including grooming of the person for sexual activity Alleged assault or neglect of a participant The use of a restrictive practice in relation to a person with disability, other than where the use is in accordance with an authorisation Not ApplicableSelect an option Not causing serious injury Resulting in serious injuryRisk RatingPlease review the Risk Matrix table before filling this section. Likelihood x Consequence = Risk Rating e.g. Unlikely 2 x Minor 2 = 4 rating is “insignificant”Risk Matrix TableLikelihoodConsequenceRisk RatingRisk Rating Actions Insignificant (1-4): Complete report and contact Director Minor (5-9): Complete report and contact Director Moderate (101-4): Refer to Director Major (15-19): Refer to Director Extreme (20-25): Refer immediately to Director Save & ResumeImmediate Internal ReportingName of Director / On call Incident reported to:DateTimeAdvice Provided by Director / On callList of all the people involved in the Incident/InjuryDetails of how the incident occurred.Injury LocationChoose File Injury Location DescriptionIncident DetailsFactual description of incident – DO NOT express opinions– Include what happened, where the incident occurred, the impact on/harm caused to the person and eventsleading to the incident.– Include names and details of witnesses.– List all emergency services, agencies/departments, contacted and their contact details (e.g. OPG, ChildSafety, Carer, NDIS, Police, Ambulance).Interventions, Assistance provided and Immediate ResponseList any breakages or damages that occurred during the incident (including owner if applicable)How the person we support would like to be involved in incident management? Should anyone else be involved on their behalf?First Aid Provided? Yes NoInitialsIf yes, by whom?Emergency Services Attended? Yes NoInitials Police Ambulance FirePolice Contact / Hospital Contact (where applicable):Police report number (where applicable):Worker Completing Incident ReportSignature Sign Here Date Report PreparedTime Report PreparedSubmit Form
