Incident Report Form

Incident Report Form
Reporting Officer Name

First NameLast Name
Gender
Aboriginal or Torres Straight Islander?
Date

DayMonthYear
Date
Address
Type a question
Injured
Medical Professional Required?
Name

First NameLast Name
Gender
Aboriginal or Torres Straight Islander?
Date

DayMonthYear
Date
Address
Type a question
Injured
Medical Professional Required?
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
Format: 0000 000 000.
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
Staff/Carer to Client must be marked as Category 1 below
Incident Category
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
Aboriginal or Torres Straight Islander?
Date Of Birth

DayMonthYear
Date
Address
Person was:
Injured
Medical Professional Required?
Client Name

First NameLast Name
Gender
Aboriginal or Torres Straight Islander?
Date Of Birth

DayMonthYear
Date
Address
Person was:
Injured
Medical Professional Required?
Client Name

First NameLast Name
Gender
Aboriginal or Torres Straight Islander?
Date Of Birth

DayMonthYear
Date
Address
Person was:
Injured
Medical Professional Required?
Staff/Carer or Other Details
Staff/Carer Name

First NameLast Name
Position/Title
Role
Person was:
Injured
Medical Professional Required?
Staff/Carer Name

First NameLast Name
Position/Title
Role
Person was:
Injured
Medical Professional Required?
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?
Details of damage
Signature of reporter:
Signature of reporter
Date

DayMonthYear
Date
Part 5 Managers Report:

to be completed by house supervisor/coordinator line manager, CEO, or agency manager.
Position
Print Name
Telephone
Format: 0000 000 000.
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?
Have immediate client safety needs been met?
Has an investigation been initiated?
Is this an incident of abuse in care?
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)?
Client manager/HR informed?
Date

DayMonthYear
Date
Time
Police Contacted?
Date

DayMonthYear
Date
Time
Police officer's name
Telephone
Format: (000) 000-0000.
Police Investigation?
Date

DayMonthYear
Date
Coroner Contacted?
Date

DayMonthYear
Date
Case number
Worksafe Victoria notified?
Date

DayMonthYear
Date
Report quality checked
Signature of Manager
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
Format: (000) 000-0000.
Incident Report Checked:
Immediate needs of the client are being suitably addressed:
All appropriate immedate actions have been taken in response to the incident:
Any identified program management failures being addressed:
Follow up action required:
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
Date

DayMonthYear
Date
Part 7: Endorsement Area/Human Resources Manager
Name
Position
Comments (optional)
Disability Services commissioner should be informed:
Child safety commissioner should be informed:
Property Portfolio informed:
Email alert required:
Signature of Manager
Date

DayMonthYear
Date
Part 8: Endorsement Managing Director
Quality of support/care review is recommended:
Comments (optional)
Signature of Managing Director
Date

DayMonthYear
Date
Should be Empty:

Incident Report Form

Who was involved?

Staff/Carer or Other Details

Internal Permalink Review