Incident Report

To be completed within 12 hours of the incident/accident occurring by witnesses or people involved in incident.

Incident details

checkbox *

Staff member

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Date of Incident *

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Time of incident *

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Injured person’s name *

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Incident location *

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Name of person reporting the incident *

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Contact details

Phone Number *

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Email *

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Witness details

Name of witness *

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Phone Number *

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Email *

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Witness’ description of the incident *

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Description of the Incident (participant/staff)

Was a Incident Near Miss *

Yes

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Identify who provided information *

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Description of injuries or impact on person (if applicable) *

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Actions taken by our organisation (e.g. first aid, ambulance called, support to person) *

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Office use only:

Report received by: *

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Date *

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Action required: *

Investigation

Continuous improvement review

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Reportable incident *

Yes

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Date advised: *

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NDIS Commission advised *

Yes

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Date advised: *

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Report type: *

5 day report

24-hour report

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Report escalated to: *

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Date report escalated *

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Other information: *

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