Incident Report Form
Section 1: Reporter Details
Name
First Name
Last Name
Role
Support Worker
Team Leader
Coordinator
Nurse
Allied Health
Other
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Section 2: Participant Details
Name
First Name
Last Name
NDIS Number
DOB
-
Month
-
Day
Year
Date
Address of Incident
Section 3: Incident Details
Date of Incident
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
At Home
SIL/SDA
Community
Day Program
Transit
Other
Type of Incident
Injury to Participant
Injury to Staff
Fall
Missing Person
Medication Error
Aggression/ Assault
Death
Unauthorised Restrictive Practices
Property Damage
Self Harm
Mental Health Episode
Other
Description of Incident:(Include detailed information – who, what, where, when, how
Section 4: People Involved
Was anyone Injured
Yes
No
If yes Please Describe
List of people involved or present:
Rows
Name
Contact Number
Role
1
2
3
4
Section 5: Actions Taken
Immediate Action Taken:
Was first aid provided?
Yes
NO
If yes, by whom and what was done?
Were emergency services contacted?
Yes
No
If yes, which service?
Police
Ambulance
Fire
Time Called:
Hour Minutes
AM
PM
AM/PM Option
Outcome:
Was any restrictive practice used?
Yes
No
If yes, complete below:
Physical
Chemical
Environmental
Mechanical
Seclusion
Duration
Is this practice part of a Behaviour Support Plan?
Yes
No
Section 6: Follow-up and Reporting
Was the NDIS Commission notified?
Yes
No
To Be Determined
Was the participant’s nominee/guardian informed?
Yes
No
Was a team leader/manager notified?
Yes
No
Was a behaviour support practitioner informed?
Yes
No
N/A
Next Steps / Follow-Up Actions Required:
Section 7: Supporting Documentation
Please attach any relevant documents, witness statements, or photos:
File(s) attached
None
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Section 8: Declaration
I declare that the information provided in this form is true and accurate to the best of my knowledge.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
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