Incident Report
Staff member name
Staff Name
*
Participant Details
Participant's Full Name
*
Participant's Address
*
Participant's Phone Number
Participant's Email
Participant's Advocate/Key Carer
Incident Details
Type of Incident
*
Acts, omissions or events occurring in relation to providing supports.
Acts by a person with disability.
Have or could have caused harm.
Have caused serious harm or risk to another person.
Date of, or disclosure of incident
*
Time of incident
*
Location of Incident
*
Describe the Incident (in as much detail as possible)
*
Type of Incident (eg. burn, fracture, cut)
*
Location of Injury (eg. face, arm, knee)
*
Was the client transferred to the doctor or hospital? (If yes, give details)
*
Immediate actions taken to give safety to the participant or persons involved
*
Witness present?
*
Yes
No
Witness's Full Name
Witness email
Witness phone number
Management to Complete
Outcome of Investigation - to be completed by management
Always ensure the person/s affected by the incident are considered and supported to participate during the investigation.
Actions to be taken - to be completed by management
Include action, person responsible and completion date.
Investigation completed by
Date completed
Name and describe each goal you are working toward.
Incident discussed with appropriate staff, participants and/or advocates?
Yes
No
Notes on discussion
Decided outcomes
Is this an NDIS reportable incident?
Yes
No
Check our Incident Management Policy and Procedure for a description of reportable incidents.
Reportable incident form sent to the NDIS?
Yes
No
Send to reportableincidents@ndiscommission.gov.au Form located in Management Qualities and Safeguards folder on Google Drive.
Date and Time Submitted
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