Incident Report Form

In the event of an incident, this report must be completed as soon as possible and submitted to your immediate supervisor.

This Incident Report Form is confidential and accessible only to authorized administrative staff. It should be used to record all incidents, whether they involve participants or staff. Please note that incident reports are no longer processed through ShiftCare.

For incidents involving a participant, ensure relevant details are documented in your shift notes and communicated during your verbal handover to keep the support team informed.

Which state did this Incident occur?*

VictoriaQueensland

Date the Incident is Reported*

Staff Name*

First NameLast Name

Staff Email*

Mobile Number*

Date the Incident occurred *

Location/ address the incident occurred*

Time the Incident occurred*

Choose from one of the following options as the incident type*

Who was involved or witnessed the incident occur (Please provide full names, contact details and if the person was a participant, support worker or witness)*

Was anyone injured? if yes, please provide name, contact details and if the person was a participant, support worker or witness)*

Describe What Happened *

What immediate actions were taken*

Upload images related to the incident here

Confirmation of completing employee: I hereby confirm that the information provided in this report is accurate to the best of my knowledge. Signature Of employee:*