Workplace Incident Report Form

Incident Report Number:

INCIDENT DETAILS

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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

Time

Email

Location of incident

Date of Incident Reporting

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Witness (1) Name (if applicable):

Witness (2) Name (if applicable):

Phone Number: (if applicable)

Email (if applicable)

TYPE OF INCIDENT

DESCRIPTION OF INCIDENT

INJURY DETAILS

Any physical injury sustained

YES
NO

Part of body injured (mark below with circle):

Mechanism of injury (tick one):

Nature of injury:

NOTIFICATION

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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

TREATMENT PROVIDED

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Lost Time Injury (LTI)?

YES
NO

Days Lost:

Details of Action Taken

SIGN OFF

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Report signed off by:

Date

Signature

Once form is completed and signed, submit the form.

INVESTIGATION

(For Official Use only)

Preliminary findings:

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

Corrective actions

Description of actions:

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Comments by Director

Findings:

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Outcomes:

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?

Sign Off

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