Incident Report
Boon Consulting
Participant
Report Date
-
Day
-
Month
Year
Person completing this form
First Name
Last Name
Participant Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
NDIS Number
Email
Alternative Contact Person
Relationship to Participant
Parent / Legal Guardian
Spouse / Partner
Family Member / Friend
NDIS Provider
Other
Contact Email
Contact Person Mobile Number
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Incident Details
Incident Date
-
Day
-
Month
Year
Who was involved in the incident?
Include full names and contact details
Who witnessed the incident?
Include full names and contact details
What happened in the lead up to the incident?
What happened during the incident?
What happened immediately after the incident?
Was anyone injured?
Was medical attention required?
Was any property damaged?
Is an insurance claim required?
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Reporting Requirements
Does any other person or organisation need to be notified?
Yes - NDIS provider
Yes - Police
Yes - NDIS Quality & Safeguards Commission
Yes - Child & Youth Protective Services
Yes - Family Member of participant
Yes - Senior Practitioner
Yes - Regulating Body (e.g. AHPRA)
No
Other
Provide details of these reports
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Actions to Take
What actions need to be taken to ensure the safety of those involved in the incident?
Has a risk assessment been done to prevent the incident recurring?
Who needs to be notified of the outcome of the risk assessment?
When were they notified?
Any additional information?
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Review
What has happened in the time following the incident?
Any additional information?
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