Incident Report Form

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PART A – Details of the incident – To be filled by the person filling up the incident form

Name

Phone number

Email Address

Client Name

Location of the Incident Participant HomeOfficeCommunity ParticipationOther

Date of incident

Time of incident

Activity being undertakenAssist Personal ActivitiesGroup Centre ActivitiesHousehold TasksInnovative Community ParticipationParticipate CommunityCommunity Nursing CareOthers

Description of the incident

Names and contact details for witnesses to the incident – if present

Was anyone injured NoYes

How many:

Reportable incidentNon reportable incident

Refer reportable incident list

The death of a person with disability.Serious injury of a person with disability.Abuse or neglect of a person with disability.Unlawful sexual or physical contact with, or assault of, a person with disability.Sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity.The use of a restrictive practice in relation to a person with disability, other than where the use is in accordance with an authorization (however described) of a State or Territory in relation to the person.Others

PART B – Details of injury – if applicable (To be filled by the person filling up the incident form)

If more than one person has been injured in this incident, please attach an additional part B for each injured person

Details of injured person

Name

Gender

Date of Birth

Work phone

Home phone

Mobile

Email

Mechanism of Injury Slip/trip/fallManual handlingBody stressingBeing hit by falling objectExposure to Chemical agentHitting an objects with part of the bodyBeing hit by moving objectsExposure to heat/radiation/electricityExposure to biological agent (including body fluid)Exposure to asbestosExposure to work stressViolenceinappropriate behaviorOthers
Nature of Injury Sprain/StrainFractureCuts/Scratch/AbrasionBruisingBurnBite/StingElectrical shockConcussionPsychologicalOthers

Date of filling up the incident form

Name of the person filling up the incident form

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