Incident Report Form

Incident Report Form
Purpose

This form is to be completed whenever an incident occurs involving a participant, staff member, visitor, or contractor connected to 360 Support Coordination services.
Reporter Details
Name

First NameLast Name
Position/Role
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date

MonthDayYear
Date
Incident Details
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Location of Incident (e.g., participant home, community venue, online, phone call, other)
Type of Incident (Tick all applicable)

Injury or IllnessAbuse or NeglectUnlawful or inappropriate sexual conductDeath of participantMissing personStaff misconductProperty damageFinancial misconductprivacy breach/Confidential issueOther
People Involved
Names of Participants

First NameLast Name
Names of Staff Members

First NameLast Name
Names of Witness

First NameLast Name
Other Relevant parties:
Incident Reporting

Provide a factual, objective account of what happened. Include:
Sequence of Events
Actions taken at the time
Any injuries or damages sustained
Incident Description (Include as much detail as possible)
Immediate Actions Taken
First Aid Provided

YesNo
Emergency Services Contacted

YesNo
Other Immediate Actions
Impact and Risk Assessment
Was Participant affected

YesNo
Risk Level

Low (Minor Incident , no injury)Moderate (medical attention needed, ongoing monitoring required)High (Serious harm, NDIS reportable incident, legal involvement)
Follow-up Actions/Recommendations
Is further action required?

YesNo
Reportable Incident Consideration
Is this incident reportable to the NDIS Commission?

YesNoUnsure - escalate to Compliance Manager
If yes, date reported to NDIS Commission

MonthDayYear
Date
Reported By

First NameLast Name
Management Review and Sign- Off

(To be completed by Manager or Compliance Officer)
Reviewed By

First NameLast Name
Position
Date of Review

MonthDayYear
Date
Corrective/Preventative Actions Implemented
Incident Closed on

MonthDayYear
Date
Confidentiality Notice:

All information in this form is confidential and must be handled according to 360 Support Coordination’s privacy and incident management policies.
Should be Empty:

Incident Report Form

Purpose

Reporter Details

Incident Details

People Involved

Incident Reporting

Immediate Actions Taken

Impact and Risk Assessment

Follow-up Actions/Recommendations

Reportable Incident Consideration

Management Review and Sign- Off

Confidentiality Notice: