Workplace Incident Report Form

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Incident Report Number:

NAME (Person completing incident form) *

Relationship with the Participant *

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

Phone Number *

Email *

Location of incident *

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
The unauthorised use of restrictive practice in relation to an NDIS participant
Others

Witness (1) Name (if applicable):

Witness (2) Name (if applicable):

Phone Number: (if applicable)

Email (if applicable)

DESCRIPTION OF INCIDENT *

Any physical injury sustained *

Part of body injured (mark below with circle):

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:

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)? *

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

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

Medically treated? *

If yes;

First aid
Medical or Dental Centre
Hospital (Admission)
Other

Lost Time Injury (LTI)? *

Days Lost:

Details of Action Taken

Report signed off by: *

INVESTIGATION

(For Official Use only)

Preliminary findings:

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

Did equipment contribute?

Was the equipment used designed for activity?

Was the equipment properly maintained?

Did the equipment fail?

Had a risk assessment been undertaken?

Did safety instructions accompany activity?

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

Were these SWP followed?

Was appropriate PPE used?

Was the involved person trained in this activity?

Did a known behaviour problem contribute?

Was there a known behaviour management plan?

Was behavioural management plan followed?

Did poor housekeeping contribute?

Did the work environment contribute?

Others:

Description of actions:

Person Responsible

Position

Findings:

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?

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.

Empowering Abilities, Inspiring Possibilities.

As part of our mission, we strive to empower everyone with a disability to be considered equal members of the community.

Our focus is on the individual, not the disability.

________________________

ABN 90 961 408 022
Victoria, Australia
Phone: 1800 934 115
info@carezoneservices.com.au
www.carezoneservices.com.au

CARE ZONE acknowledges Aboriginal and Torres Strait Islander peoples as Traditional Owners of the lands and waterways of Australia. We pay our respects to the people, the cultures and the elders past, present and emerging.

We support Aboriginal people's right to self-determination and culturally safe services.

The Care Zone is committed to providing safe, accessible, and inclusive services to all members of the community.

NDIS Service Price Guide

(Employer ID: 4-JP95HRF)

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