Behaviour Incident Report Form
1. Reporter Details
Name
*
First Name
Last Name
Position/Role:
*
Support Worker
Behavior Practitioner
Team Leader
Other
Date of Report
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
2. Participant Information
Participant Full Name:
*
First Name
Last Name
NDIS Number:
Date of Birth
-
Month
-
Day
Year
Date
Support Setting:
*
Home
SIL/SDA
Community
Day Program
Respite
School
Other
3. Incident Overview
Date of Incident:
*
-
Month
-
Day
Year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Incident Location and People Involved:
*
Describe the Behavioral Incident in Detail:(What happened? What was observed? Include sequence of events.)
*
4. Behavioural Presentation
Type of Behaviour: (tick all that apply)
*
Aggression to others
Self-harm
Absconding/Running away
Property damage
Refusal
Verbal aggression
Throwing items
Crying/yelling/screaming
Threatening Behaviour
Other
Details of Behaviour
Was the participant or others injured?
*
Yes
No
If yes, describe the injury and who it affected:
What triggered the behaviour? (Known or suspected)
*
Change in routine
Environmental triggers (noise, crowd)
Denied request
Sensory overload
Unknown
Other:
Details of Triggers
5. Staff Response
Actions Taken by Staff:
Verbal redirection
Provided space
Followed Positive Behaviour Support Plan
PRN medication offered/administered
Restrictive practice used (see next section)
Called for help
Notified guardian
Other
6. Restrictive Practice
Was a Restrictive Practice used?
Yes
No
If Yes, Type
Physical
Mechanical
Chemical
Seclusion
Environmental
Duration
Describe in detail:
Was the Restrictive Practice authorised in a current Behaviour Support Plan (BSP)?
Yes
No
Unknown
Was the NDIS Commission notified (if Unauthorised Restrictive Practices)?
Yes
No
To be done by:
7. Follow-up and Review
Was the Behaviour Practitioner notified?
Yes
No
Parent/Guardian informed?
Yes
No
Team Leader/Manager notified?
Yes
No
Recommendations / Next Steps:
BSP to be reviewed
Team debrief
Additional staff training
Seek functional behaviour assessment
Other
Additional Notes
Attachments ( Injury Report, Witness Statement, Incident Photo, Other Supporting Documents)
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8. Staff Member Completing Report
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
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