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Example
Home
Incident report
Progress Notes
Referral Form
Sample Page
Incident Report form
Step
1
of
2
50%
Email
(Required)
Reporting Staff details (Name)
(Required)
Date of Entry
(Required)
MM slash DD slash YYYY
This incident concerns
(Required)
Worker
Participant (please enter details below)
Participant Family (please enter details below)
Others
Participant details (Name)
(Required)
Location of the incident
(Required)
Witness 2 (Name of witness)
Witness 2 (Name of witness)
Description of Incident
(Required)
Injury details (please detail the part of the body injured)
(Required)
Type of Incident
Death (Report to NDIS)
Injury/illness/medical concern (Report to participant doctor, family)
Violence, abuse, neglect, exploitation & discrimination
unlawful sexual or physical contact with or assault
sexual misconduct
behaviours of concern
Unauthorized use of a restrictive practice in relation to NDIS participant
medication error
detected waste, infectious or hazardous substances
property damage
equipment failure
motor vehicle accident
abscounding
Follow up Investigation (preliminary findings)
(Required)
Did the incident occur as part of the involved person's normal activities?
Yes
No
NA
Did equipment contribute?
Yes
No
NA
Was the equipment used designed for activity?
Yes
No
NA
Was the equipment properly maintained?
Yes
No
NA
Did the equipment fall?
Yes
No
NA
Had a risk assessment been undertaken?
Yes
No
NA
Did safety instructions accompany activity?
Yes
No
NA
Are there documented safe work procedures (SWP) for activity?
Yes
No
NA
Were these SWP followed?
Yes
No
NA
Was appropriate PPE used?
Yes
No
NA
Was the involved person trained in this activity?
Yes
No
NA
Did a known behaviour problem contribute?
Yes
No
NA
Was there a known behaviour management plan?
Yes
No
NA
Was it followed?
Yes
No
NA
Did poor housekeeping contribute?
Yes
No
NA
Did the work environment contribute?
Yes
No
NA
Others (fill detail below)
Yes
No
NA
Corrective Actions
(Required)