Incident Report Form

Incident Report Form
Reporting Officer Name

First NameLast Name
Gender

MaleFemaleUnidentified
Aboriginal or Torres Straight Islander?

YesNo
Date

DayMonthYear
Date
Address
Type a question

ParticipantVictimWitness
Injured

YesNo
Medical Professional Required?

YesNo
Name

First NameLast Name
Gender

MaleFemaleUnidentified
Aboriginal or Torres Straight Islander?

YesNo
Date

DayMonthYear
Date
Address
Type a question

ParticipantVictimWitness
Injured

YesNo
Medical Professional Required?

YesNo
Complete this form to report incidents involving and/or impacting upon clients in services delivered by Permalink Services and funded by the National Disability Insurance Scheme. Incidents are categorized according to actual/alleged impact on clients.

Use the Incident Report Guide to assist in completing the form.

If more space is required for any section, please attach an additional clearly labelled page/s.
Reporting officer's name
Telephone number
Position title
Permalink Service Areas
Reference number: (if applicable)
Date of incident

DayMonthYear
Date
Hour Minutes
If you did not see the incident:
Date you were first told about the incident: DD/MM/YYYY

DayMonthYear
Date
Hour Minutes
Address/location of incident
For Incidents involving assault

Client to ClientClient to Staff/CarerStaff/Carer to ClientClient to OtherOther to Client
Staff/Carer to Client must be marked as Category 1 below
Incident Category

Category 1Category 2
Refer to Incident types. For items with an asterisk * you must select Category 1 for any Reportable Incidents.
* Only mark 'victim' when incident involves assault. Staff/carer or others: details Please complete for each staff member/carer or others involved in the incident, including any witnesses.
Who was involved?

Client details
Client Name

First NameLast Name
Gender

MaleFemaleUnidentified
Aboriginal or Torres Straight Islander?

YesNo
Date Of Birth

DayMonthYear
Date
Address
Person was:

ParticipantVictimWitness
Injured

YesNo
Medical Professional Required?

YesNo
Client Name

First NameLast Name
Gender

MaleFemaleUnidentified
Aboriginal or Torres Straight Islander?

YesNo
Date Of Birth

DayMonthYear
Date
Address
Person was:

ParticipantVictimWitness
Injured

YesNo
Medical Professional Required?

YesNo
Client Name

First NameLast Name
Gender

MaleFemaleUnidentified
Aboriginal or Torres Straight Islander?

YesNo
Date Of Birth

DayMonthYear
Date
Address
Person was:

ParticipantVictimWitness
Injured

YesNo
Medical Professional Required?

YesNo
Staff/Carer or Other Details
Staff/Carer Name

First NameLast Name
Position/Title
Role

Paid StaffCarer
Person was:

ParticipantVictimWitness
Injured

YesNo
Medical Professional Required?

YesNo
Staff/Carer Name

First NameLast Name
Position/Title
Role

Paid StaffCarer
Person was:

ParticipantVictimWitness
Injured

YesNo
Medical Professional Required?

YesNo
Describe the incident and the immediate response of staff. This section should be a brief, factual account of the incident. Include impact on client; who was involved; how, where and when the incident occurred; who did what; who (if anyone) was injured and the nature and extent of injuries (if applicable).
Was any property or equiptment damaged?

YesNo
Details of damage
Signature of reporter:
Signature of reporter

Clear
Date

DayMonthYear
Date
Part 5 Managers Report:

to be completed by house supervisor/coordinator line manager, CEO, or agency manager.
Position
Print Name
Telephone
Brief summary of incident (for all incidents) Provide a brief summary of incident in 20 words or less
What actions have been taken and what follow-up actions will be taken in response to the incident? Please describe what actions have been taken to address safety risks and what will be done to prevent recurrence of the incident.
Is this an incident of staff to client assault?

YesNo
Have immediate client safety needs been met?

YesNo
Has an investigation been initiated?

YesNo
Is this an incident of abuse in care?

YesNo
Please provide details: e.g. staff or carer stood down or client removed from placement, Quality of Care review or other review recommended.
Compulsory treatment: Are any of the clients subject to compulsory treatment under the Disability Act (2006)?

YesNo
Client manager/HR informed?

YesNoNA
Date

DayMonthYear
Date
Time
Police Contacted?

YesNoNA
Date

DayMonthYear
Date
Time
Police officer's name
Telephone
Police Investigation?

YesNoNA
Date

DayMonthYear
Date
Coroner Contacted?

YesNA
Date

DayMonthYear
Date
Case number
Worksafe Victoria notified?

YesNANo
Date

DayMonthYear
Date
Report quality checked
Signature of Manager

Clear
Date

MonthDayYear
Date
Time
Forward completed incident report to Permalink Support Services Office to hr@permalink.com.au and contact HR immediately on 03 9084 7494

Client Incident Report Form - 2023 Version 2.0 Page 3 of 4
Internal Permalink Review
Part 6: Endorsement Service Team Leader To be completed by manager e.g. disability accommodation manager, disability area manager, child protection manager, housing manager, youth justice manager, housing services manager.
Name
Position
Telephone
Incident Report Checked:

YesNo
Immediate needs of the client are being suitably addressed:

YesNo
All appropriate immedate actions have been taken in response to the incident:

YesNo
Any identified program management failures being addressed:

YesNoNA
Follow up action required:

YesNo
What actions have been taken and what follow up actions will be taken? Please describe what actions have been taken to address safety risks and what will be done to prevent recurrence of the incident.
Signature of Manager

Clear
Date

DayMonthYear
Date
Part 7: Endorsement Area/Human Resources Manager
Name
Position
Comments (optional)
Disability Services commissioner should be informed:

YesNo
Child safety commissioner should be informed:

YesNo
Property Portfolio informed:

YesNo
Email alert required:

YesNo
Signature of Manager

Clear
Date

DayMonthYear
Date
Part 8: Endorsement Managing Director
Quality of support/care review is recommended:

YesNo
Comments (optional)
Signature of Managing Director

Clear
Date

DayMonthYear
Date
Should be Empty:

Incident Report Form

Who was involved?

Staff/Carer or Other Details

Internal Permalink Review