Incident Report

1. LOCATION & TIME DETAILS OF INCIDENT / ACCIDENT

Date of Incident:

Time of Incident:

Area:

The exact location of the Incident:

Street

Suburb

State

Person Reporting:

Participant Worker Visitor Public

Contact Number

2. DESCRIPTION OF INCIDENT

Give a full description of the incident:

How was the injury or damage sustained?

Consultation with the participant

3. NATURE OF INCIDENT

Non- Reportable Incidents:

Injury- First Aid treatment Restricted Work Waste Incident Medication Incident

Reportable Incidents (Incidents must be reported to NDIS Commission with the given time frame):

Other

The following incidents (including allegations) arising must be reported to the NDIS Commission:
• The death of an NDIS participant.
• Serious injury of an NDIS participant.
• Abuse or neglect of an NDIS participant.
• Unlawful sexual or physical contact with, or assault of, an NDIS participant.
• Sexual misconduct committed against, or in the presence of, an NDIS participant, including grooming of the NDIS participant for sexual activity.
• The unauthorised use of restrictive practice by an NDIS participant.

4. INJURY INFORMATION (Person involved in the incident/accident, if more than one fill out a separate form)

Name

Job Title

Date of Birth

Sex

Male Female

Status

Participant Worker Visitor Public

Phone Number

NDIS Number

Caused By

Full Name of the First Aider (if applicable)

Description of Action Taken / First Aid Treatment.

5. PROPERTY DAMAGE (Including Environmental Impacts)

6. WITNESSES (Attach Copies of Witness Statements)

Upload Relevant Documents (Eg: Witness Statements)

Consent

I agree with the Privacy Policy before submitting this form.

Ensuring Safety and Prompt Resolution

Incident Report Form