Incident Report

Incident Report

Email us if you can't fill it out at - admin@cleancare group.com.au
To be completed within 12 hours of the incident/accident occurring by witnesses or people involved in incident.
Incident Details

Participant - Provide NDIS NumberStaff MemberOther
Date of incident

MonthDayYear
Date
Time of incident
Injured person's name
Incident location
Name of person reporting the incident
Phone
Email
example@example.com
Date of report

MonthDayYear
Date
Name of witness
Phone
Email
example@example.com
Witness' description of the incident*
Description of the Incident (participant/staff) Identify who provided information (for future investigation)
Identify who provided information (for future investigation)
Description of injuries or impact on person (if applicable)
Actions taken by our organisation (e.g. first aid, ambulance called, support to person)
Report received by (For Office Use only)
Action Required

InvestigationContinous Improvement
Date

MonthDayYear
Date
Reportable Incident

YesNO
Date advised/reported

MonthDayYear
Date
NDIS Commission advised*

NOYes - Date advised
Date

MonthDayYear
Date
Report Type*

5-Day Report24-hour Report
Report escalated to
Date report escalated

MonthDayYear
Date
Other Information
Please verify that you are human*
Should be Empty: