Incident Report – Investigation Form – Streams of Living Water Inc.

Step 1 of 4

Participant Name

Client Details

Surname: Other Name/s:

Gender

Address:

Telephone

HRN

DOB

Date of Incident:

Time of Incident

Location of Incident:

Reporting Persons Details

Client Details

Surname: Other Name/s:

Gender

Employer

Telephone:

Service Provided to Client

Choose

Is this a reportable incident?

Or non-reportable incident?

Refer reportable incident list

1. the death of a person with disability; or
2. serious injury of a person with disability; or
3. abuse or neglect of a person with disability; or
4. unlawful sexual or physical contact with, or assault of, a person with disability; or
5. sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity; or
6. the use of a restrictive practice in relation to a person with disability, other than where the use is in accordance with an authorisation (however described) of a State or Territory in relation to the person.

If this is a Reportable Incident, please refer to the Incident Management Policy for how to report this incident on the NDIS Commission Portal and continue to complete this incident form for internal purpose.

If this is not a reportable incident, continue to complete this incident form and submit to your manager or supervisor for review.

What is the Risk Rating of the is Incident?

Level (Briefly explain why you’ve rated at this level: )

Catastrophic

Major

Moderate

Minor

Insignificant

Name of Witness:

Phone:

Was First Aid Required?:

Yes

If yes who was the First Aid provider?:

Was medical treatment required?:

Yes

If yes who was the treating doctor?:

Was hospital treatment required?:

Yes

If yes who was the treating doctor?:

Details of incident or accident:

Date

Time of Injury

Activity engaged in at time of incident:

Exact location of person at time of incident:

Describe how and what happen (please give full details & include a diagram, if appropriate. Use a separate sheet if necessary. Please include car registration number if reporting a Motor Vehicle Accident.)

Physical Harm

Nature of injury/illness (e.g. burn, sprain, cut etc.)

How injury occurred (e.g. fall, grabbed by person, muscular stress):

Treatment administered if required:

Yes

Treatment:

Referral required:

Yes

Who to:

First aid attendant (Print Name):

Signature:

INCIDENT OR ACCIDENT INVESTIGATION

Is this a reportable incident?

Yes

N/A

Which regulators have been notified?

Have you referred to the NDIS Incident Report Policy (for reportable incidents)

Yes

Other parties to advise about the incident? (click "+" to add column)

Work Unit/Individual

Date advised

Method of contact

Consideration for further Risk Management

Risk Management Plan

Risk Management plan to be reviewed by

Date due

Approval:

Reporting Persons Comments:

Signature

Name:

Date

Line Managers Comments:

Signature

Name

Date

Senior Managers Comments:

Signature

Name

Date

Senior Directors Comments

Signature

Name

Date

HOMECARE

ACCOMMODATION

COMMUNITY SUPPORT

Incident Report – Investigation Form

Participant Name

Reporting Persons Details

What is the Risk Rating of the is Incident?

Details of incident or accident:

Physical Harm

INCIDENT OR ACCIDENT INVESTIGATION

Consideration for further Risk Management

Approval: