Workplace Incident Report Form

Step 1 of 10

Workplace Incident Report Form

Incident Report Number:

Step 2 of 10

INCIDENT DETAILS

NAME (Person completing incident form)*

Relationship with the Participant*

Staff Member / Worker Participant (Self) Participant’s (Friend/Family/Guardian or Advocate) Others

Phone Number*

Date & Time of Incident*

Email*

Location of incident*

Date of Incident Reporting*

Witness (1) Name (if applicable):

Witness (2) Name (if applicable):

Phone Number: (if applicable)

Email (if applicable)

TYPE OF INCIDENT*

The Death Injury/illness/medical concern Violence, abuse, neglect, exploitation & discrimination Unlawful sexual or physical contact with, or assault Sexual misconduct Behaviours of concern Medication error Detected waste, infectious or hazardous substances Equipment failure Motor vehicle accident Absconding Meal Management Others The unauthorised use of restrictive practice in relation to an NDIS participant

DESCRIPTION OF INCIDENT*

Step 3 of 10

INJURY DETAILS

Any physical injury sustained*

YES NO

Part of body injured (mark below with circle):

Option 1

Mechanism of injury (tick one):

Falls/trips/slips Hit by moving objects Body stress/manual handling Chemicals/other substances Mental stress Hitting objects with part of the body Sound/pressure Heat/electricity Biological factors Vehicle incident

Nature of injury:

Head/intracranial Fractures Laceration/amputation Internal organ damage Burns Injury to spinal cord Joint/ligament damage Foreign body Strain/Pain Electrocution Diseases/conditions detail:

Step 4 of 10

NOTIFICATION

Reportable Incident?*

YES NO UNSURE

NDIS Commission notified?*

YES NO UNSURE

Immediate notification?*

YES NO UNSURE

5 Day notification?*

YES NO UNSURE

Does this incident require to notify other parties (e.g. notifying family/guardian if the participant is a child)?*

YES NO

Does this incident require Police notification (e.g. sexual misconduct etc.)?*

YES NO

Does the severity of this incident require notification to Safe Work?*

YES NO

Step 5 of 10

TREATMENT PROVIDED

Medically treated?*

YES NO

If yes;

First aid Medical or Dental Centre Hospital (Admission) Other

Lost Time Injury (LTI)?*

YES NO

Days Lost:

Details of Action Taken

Step 6 of 10

SIGN OFF

Report signed off by:*

Date*

Signature*

Once form is completed and signed, submit the form.

INVESTIGATION

(For Official Use only)

Preliminary findings:

Step 7 of 10

Root causes analysis

Did the incident occur as part of the involved person’s normal activities?

YES NO N/A

Did equipment contribute?

YES NO N/A

Was the equipment used designed for activity?

YES NO N/A

Was the equipment properly maintained?

YES NO N/A

Did the equipment fail?

YES NO N/A

Had a risk assessment been undertaken?

YES NO N/A

Did safety instructions accompany activity?

YES NO N/A

Are there documented safe work procedures (SWP) for activity?

YES NO N/A

Were these SWP followed?

YES NO N/A

Was appropriate PPE used?

YES NO N/A

Was the involved person trained in this activity?

YES NO N/A

Did a known behaviour problem contribute?

YES NO N/A

Was there a known behaviour management plan?

YES NO N/A

Was behavioural management plan followed?

YES NO N/A

Did poor housekeeping contribute?

YES NO N/A

Did the work environment contribute?

YES NO N/A

Others:

YES NO N/A

Step 8 of 10

Corrective actions

Description of actions:

Person Responsible

Position

Deadline

Step 9 of 10

Comments by Director

Findings:

Completed On

Status:

Open More action required Closed Effectively

Outcomes:

Run training/induction session Review/update risk register Review/amend relevant process/documents Create a new procedure Others:

Completion Checklist

Incident details fully completed by the worker/person involved? Relevant Manager completed and signed? Incident register completed? If Property damage, maintenance request completed? Did the director complete and signed? Is feedback given to participant/worker and others involved?

Step 10 of 10

Sign Off

Investigation completed by:

Acknowledgement

I acknowledge that Participant / Participant’s representative/ Worker, subject to this incident report have been engaged and informed with the detail of the investigation. I am satisfied with the outcome. I have provided & retained a copy of this report as per policy and procedures of Care Zone.

Date Completed

Your responses are submitted securely and stored in Care Zone's confidential records.