INCIDENT REPORT FORM 25-26

Reporting officer's name

Telephone number

Position title

Permalink Service Areas

Reference number: (if applicable)

Date of incident

Date

Hour Minutes

If you did not see the incident:

Date you were first told about the incident: DD/MM/YYYY

Date

Hour Minutes

Address/location of incident

Incident Type

For Incidents involving assault

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.

Participant Name

First NameLast Name

Gender

MaleFemaleUnidentified

Aboriginal or Torres Straight Islander?

YesNo

Date Of Birth

Date

Address

Person was:

ParticipantVictimWitness

Injured

YesNo

Medical Professional Required?

YesNo

Participant Name

First NameLast Name

Gender

MaleFemaleUnidentified

Aboriginal or Torres Straight Islander?

YesNo

Date Of Birth

Date

Address

Person was:

ParticipantVictimWitness

Injured

YesNo

Medical Professional Required?

YesNo

Participant Name

First NameLast Name

Gender

MaleFemaleUnidentified

Aboriginal or Torres Straight Islander?

YesNo

Date Of Birth

Date

Address

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

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

Date

Incident Report Form

Who was involved?

Staff/Carer or Other Details