Incident Report Form-0024

INCIDENT REPORT

FORM-0024 (To report an incident, please provide the following information)
Date and time when incident actually occurred:*

DayMonthYearHourMinutesAM/PM Option
Who was involved in the Incident?*

First NameLast Name
List names of anyone else involved in the incident (if applicable):
Incident details:*
Details of the near miss (potential harm), or incident (actual harm) that came to a person or property
Do you wish to add a file?

Browse Files
E.g. photograph of injury or damage Cancelof
Incident location:
E.g. street address, room name or number, indoor/outdoor area
List details of any witness and include contact details.
Was a report of the incident notified to any one else? Please include person's NAME and TITLE.
If POLICE or AMBULANCE attended, please include names and phone numbers
Person who is reporting this incident?*

First NameLast Name
Any other general comments:
E.g. the type of first aid administered, if person attended GP, if person admitted to hospital
Would you like us to contact you? Note: Employees do not need to complete.

YesNo
Email:
example@example.com
Phone number:

Area CodePhone Number
MANAGER USE ONLY

MANAGER INVESTIGATION AND RESPONSE
Manager Name (responsible for INVESTIGATING and CLOSING incident report)

First NameLast Name
Will you be completing an investigation of this incident?

YES - please complete all relevant fields belowNO - please proceed to the end of this form and indicate the date this matter was closed
Investigation start date:

DayMonthYear
Date
Please indicate if this is a REPORTABLE INCIDENT:

Death of a person with disabilitySerious injury of a person with disabilityAbuse or neglect of a person with disabilitySexual misconduct, committed against, or in the presence of, a person with disability, including grooming of the person with disability for sexual activityUnauthorised use of restrictive practices in relation to a person with disabilityUnsureNone of the above
Using the Risk Matrix below, determine the level of risk:

Very HighHighMediumLow
What are the circumstances that lead up to the incident?
Rather than speculate on cause, please list the facts of events immediately preceding the incident. Diary notes, witness statements and camera footage can be helpful in this task.
What immediate actions were taken in response to the incident?
Include any actions taken to make people safe and to support the person affected by the incident
Who/what have you consulted in undertaking this assessment?
E.g., incident reports, diary notes, impacted person's informal supports or guardian, behaviour support practitioner.
How have the impacted person's views been considered in your investigation?
You must consult with the person/s impacted by the incident, and include details of the interaction here.
Can control measures be put in place to reduce the level of risk in the future?*

YesNoUnsure
If YES, please list the control measures here. If NO or unsure, please give reasons for why:*
E.g., Can the risk be eliminated, or the support environment, type and frequency be modified? Do staff need additional training or information to help reduce the risk?
Person responsible for implementing control measures

First NameLast Name
Control measures DUE:

DayMonthYear
Date

Steps Required to Complete Investigation

Rows	Task required	Assigned to	Completed
1.
2.
3.
4.
5.
6.

MANAGER to indicate date confirming that the above control measure/s have been completed and/or the matter is CLOSED.

DayMonthYear
Date
Should be Empty:

INCIDENT REPORT