Incident Report Form


    Is this report part of a Reportable Incident?

    STAFF TO COMPLETE

    Date & Time of incident:

    Address incident occurred:

     

    Client name:

    What was the main objective of the shift?

    Staff name:

    Staff Role:

    Staff Contact number:

    Staff email:

     

    PROGRAM AREA (Tick relevant)

    AccommodationCommunity SupportAged CareSupport CoordinationChildren and Young People

     

    CLASSIFICATION OF INCIDENT (Tick relevant)

    AccidentIncidentCritical/Reportable IncidentRestrictive PracticeNear Miss/Hazard

     

    STAFF TO COMPLETE

    Describe the incident. (What happened?)

    Describe the circumstances leading up to the incident. (What caused/ led to the incident to happen?)

     

    IMMEDIATE ACTION TAKEN

    What immediate action did you take in response to the accident/ incident/ near miss/hazard?

     

    Was the family member/ legal guardian notified?

    YesNo

    Time

    Was first aid provided?

    YesNo

    Details (what was injured and how was first aid provided):

    Was there a hospital transfer required?

    YesNo

    Details (where was the injury and to what extent):

    If staff injury, is workers compensation likely?

    YesNoUnknown

    Has the hazard been removed / reported?

    YesNo

    Time

     

    Employee Name

    Date

     

    MANAGEMENT TO COMPLETE

    Responsible Manager

    ACTION PLAN FOR IMMEDIATE AND LONG-TERM RESOLUTION

    What/Action

    Who

    When

    Is a critical incident review required?

    YES     NO

    SENIOR MANAGER TO COMPLETE

    1          2          3          4          Reportable

    Are the preventative actions adequate?

    YES     NO

    If No, explain what further actions are required:

    Evaluation – Details of actions/review

    Incident Closed  -   Improvement Required   -  Client Check in completed  -   Added to Register  -   Hazard Removed  -   For SLT

     

    Senior Manager

    Date Finalised