Incident Report Form

Incident Report Form

Please provide detailed information about the incident you are reporting.
An ‘incident’ is:
- an act, omission, event or circumstance that has or could have caused harm to a person with disability, or
- when a person with disability has caused serious harm or the risk of serious harm to another person.
Date of Reporting

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Full Name of person completing this form

First NameLast Name
Email Address of person completing this form
example@example.com
Contact Number of person completing this form
mobile or phone
Participant involved in incident
Full name of the participant
NDIS NO
If required. If known
Participant's SC
Type of Incident
Other comment
When did you become aware of the incident?

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
How did you become aware of incident?
Other comment
What Happened
Date and Time of Incident

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Location of the incident
where it happened e.g. participant's home, bathroom, somewhere in the community ect.
Describe the Incident
Has the participant experienced any injury, harm or other impact?
Actions Taken/Immediate Response
What actions were taken to protect the participant or others? What support was offered to the participant, and what were their wishes?
Is the participant safe now?
Has this incident happened before?
describe
Was there anyone else involved and/or witness?
Person involved/witness
Names and Contact Information and how they were involved.
Any supporting documents or evidence?

Cancelof
Emergency Services and Notifications
Police, Ambulance or first aid Required?
If yes, please describe
For example: Police (Knox police station - police officer's details. Ambulance 000 or what first aid was provided.
Was child representative, plan nominee or guardian notified?
Date of notification

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Severity Level
🔵Level 1 – Low Severity (Routine Monitoring)
Document for tracking, trends, and future planning; no immediate risk to safety.
- Missed or late appointments
- Service refusal (non-critical)
- Minor complaints or grievances
- Early signs of distress or mental health decline
- Environmental risks noted (but not urgent)
- Behavioural concerns (non-threatening)
- Changes in living arrangements or support needs
- Non-adherence to support plans
- Concerns raised by carers or other providers
🟢 Level 2 – Minor Incidents
Internal follow-up may be needed; risk is minimal but growing.
- Injury not requiring medical treatment
- Breach of privacy or confidentiality (minor)
- Unusual behaviour with no immediate risk
- Support worker not showing up
- Delay in service delivery affecting routine
- Participant refuses access to the home or support services
- Equipment not functioning properly (no harm caused)
🟡 Level 3 – Moderate Risk Incidents
Requires internal incident management, may need team response.
- Medication errors (no serious harm)
- Repeated service disruptions
- Minor aggression or verbal threats
- Participant showing signs of isolation or worsening condition
- Family conflict impacting support
- Financial concerns or risk of exploitation (not confirmed)
- Police contacted for welfare check (no incident occurred)
🟠 Level 4 – Major Incidents
Escalate to management, risk to safety is present or significant service failure.
- Hospitalisation due to service breakdown
- Aggression or physical altercations (no serious injury)
- Participant evicted or at risk of homelessness
- Confirmed financial abuse or exploitation
- Support staff harmed by participant
- Major equipment failure leading to potential injury
- Repeated failure to follow safety protocols
- Missing person (brief duration, found quickly)
🔴 Level 5 – Critical/Incidents
Must be reported and documented immediately.
- Death of a participant
- Serious injury (e.g., fractures, head trauma)
- Sexual abuse or misconduct
- Physical, emotional, or psychological abuse or neglect
- Missing person (extended, vulnerable client)
- Unlawful or inappropriate sexual conduct
- Suicide attempt or serious self-harm
- Unauthorised use of restrictive practices
- Police involvement due to violent incident or crime
- Confirmed or suspected criminal behaviour affecting the participant
Incident Severity Level
Select the severity level that best describes the incident.
NDIS Reportable Incident Check
When must an incident be reported to the NDIS Commission?

NDIS providers must notify the NDIS Quality and Safeguards Commission of reportable incidents that occur, or are alleged to have occurred, in connection with the NDIS supports or services they deliver.

Not every incident involving an NDIS participant is automatically reportable.

Reportable incident categories

The following incidents must be reported by registered NDIS providers when the reporting requirements are met:
- Death of a person with disability.
- Serious injury of a person with disability.
- Abuse or neglect of a person with disability.
- Unlawful sexual or physical contact with, or assault of, a person with disability.
- Sexual misconduct against, or in the presence of, a person with disability, including grooming.
- Unauthorised use of a restrictive practice
Reporting timeframes
Within 24 hours: For the first five categories above.
Within 5 business days: For unauthorised restrictive practices that have not caused harm.
Within 24 hours: If an unauthorised restrictive practice has caused harm.
For incidents requiring a 24-hour notification, additional information is generally required within five business days.
Did the incident occur in connection with NDIS supports or services?
Could this be a NDIS reportable incident?

Incident Report Form

What Happened

Emergency Services and Notifications

Severity Level

NDIS Reportable Incident Check

Management