Incident Report

Red Book: Incident Report
Eg. One client hit another, fire in kitchen, aggressive stranger on property.
Date of Incident

DayMonthYear
Date
Who was involved in the incident? ('Involved' can mean you found the incident ie came across aggressive stranger on property)

ClientStaffOther
Names of Client, Staff or Other individuals involved in Incident
Email, phone and address (if not a client or staff)
Client was on level:
Was the person involved injured?

YesNo
What Severity Assessment Code does the injury have applied to it?*
Describe the incident
Please upload any relevant photos for documentation or insurance purposes

Cancelof
Were there any 'lemons' surrounding this event? (ie causative factors that could have been avoided)

YesNo
Describe the lemons surrounding this event (Eg. Staff to client ratio was low resulting in less than optimal supervision):
Recommended Actions
Recommendations by staff member for procedural tweaks to our system should a similar event occur?
Are there any staff members involved in the incident who would like to have a debrief with an RLNZ staff member about the incident or to get support? If you select yes, we will arrange a formal debrief for you. Please contact the on-call person if you need immediate support.

YesNo
Name of Staff Member completing the above part of this form?

First NameLast Name
SAC 1 or 2 event

All SAC 1 and 2 events are to be reported to HSQC within 15 days
Should be Empty:

Red Book: Incident Report