Is this report part of a Reportable Incident?YesNo
STAFF TO COMPLETE
Date & Time of incident:
Address incident occurred:
What was the main objective of the shift?
Staff Contact number:
PROGRAM AREA (Tick relevant)
AccommodationCommunity SupportAged CareSupport CoordinationChildren and Young People
CLASSIFICATION OF INCIDENT (Tick relevant)
AccidentIncidentCritical/Reportable IncidentRestrictive PracticeNear Miss/Hazard
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?
Was first aid provided?
Details (what was injured and how was first aid provided):
Was there a hospital transfer required?
Details (where was the injury and to what extent):
If staff injury, is workers compensation likely?
Has the hazard been removed / reported?
MANAGEMENT TO COMPLETE
ACTION PLAN FOR IMMEDIATE AND LONG-TERM RESOLUTION
Is a critical incident review required?
SENIOR MANAGER TO COMPLETE
1 2 3 4 Reportable
Are the preventative actions adequate?
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
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