Incident Report Form

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Name of Person submitting this report*

First NameLast Name

Date of Submission*

Date

Reporter's Contact Number*

Reporter's E-mail:*

example@example.com

Role*

House Manager/Team LeaderSupport WorkerHead Office/Admin StaffOther

1

Must advise line manager within 2 hours of incident occuring that has resulted in a serious outcome, such as:

The death of a person
Serious injury or illness, requiring immediate/urgent treatment as an in-patient in a clinical setting (e.g., person has been admitted to hospital and requires at least 1 overnight stay)
Serious head, eye, burn, neck, spinal injury, or laceration
Loss of bodily function
Exposue to a hazardous substance that requires medical treatment within 48 hours
Uncontrolled leakage of a hazardous substance
Uncontrolled implosion, explosion, or fire
Uncontrolled escape of gas or steam

2

Must advise line manager within 12 hours of incident occurring, in situation such as:

Any ERROR in medication (e.g., wrong dose, time, drug, person; medication count discrepency)
Any call to, or attendance by, emergency services or after-hours medical support (e.g., locum doctor, nurse on call)
Sexual advancements or harrassment (mandatory reporting)
Self-injurious/self-harming behaviours
Suicidal ideation
Money ledger discrepency
Significant medical change
Any form of abuse (mandatory reporting)

3

Must advise line manager within 24 hours of incident occuring, in situations such as:

Substance use or misuse (e.g., smoking cigarettes indoors; any use of drugs and/or alcohol)
Unsecured chemicals
Threats, intimidation, and/or otherwise inappropriate behaviour (e.g., verbal aggression/hositility, social disturbance)
Significant behavioural change
Refusal of medication / missed dose
Adverse reaction to/resulting from medication (that is non-critical and/or not administered by AmeCare)
Accidental/purposeful property damage
Breach of privacy and/or confidentiality
Any hazard relating to Occupational Violence and/or Work Health & Safety

What is the nature of this report?*

Client Name:*

First NameLast Name

Client Date of Birth (DOB)*

Date

Client NDIS Reference #*

Were there two (2) people present at the time PRN was administered?*

YesNo

If Yes, staff name:

If No, specify handover time period & which staff member was present during handover:

Type of Drug*

e.g., Name of medication

Reason for administering PRN*

Preventative or reactive response to, e.g., aggression, property damage, self-injurious behaviours, etc

Minimum two (2) strategies used BEFORE administering PRN*

Dose & Time/s administered*

List multiple dose/time intervals if required

PRN Count*

Please specify how much PRN was in the medication pack/original container BEFORE and AFTER the PRN was administered

Who was notified (include date, time, and method of contact)*

e.g., was authorisation sought before, or was someone contacted after, PRN was administered?

Outcome (include additional information if required)*

E.g., was additional PRN required? was the PRN effective or ineffective? did the client deescalate, or heighten further?

Were emergency services in attendance? (Select all that apply)*

YesNot applicable

If Yes, which services?

What actions were taken by emergency services?

E.g., names of attending officers, client taken from premises to another location, advice from officers, etc

Where the incident occurred

Specify multiple locations if required

Who was affected

E.g., witnesses to the event, persons involved, injuries sustained

Who was notified (specify, time, date, and method of contact)

E.g., affect persons' next of kin, emergency contact

Who was notified from AmeCare (include what directions were given)

E.g., admin team, management, team leader, after-hours contact

Additional information & details about the incident (information must be a factual and objective recount of events)

E.g., timeline from beginning of the incident to how the incident resolved

Signature of person submitting this form*

Incident Report Form

Step 1

Step 2

PRN Administration