Only Care - Accident/ Incident Report

DateHourMinutesAM/PM Option

PART 1: REPORTER DETAILS

Confirmation Emailexample@example.com

PART 2: INCIDENT DETAILS

If you were not around when the incident happened, specify the date and time you were first told about the incident:

Choose the Incident Category that best describe the event. Choose from subcategory below.

Give a short description of incident.

Loss of or unauthorized disclosure of client informationPrivate client documents not stored according to privacy requirementsLoss or unauthorised disclosure of papers/files/USBs containing client informationUnauthorized disclosure of client information by staff on social media

Provide details in Part 4.

How did the client fall?

Early detection of hazards help to eliminate or decrease work-related injuries.

Provide details in Part 4.

List down the names of each drug in Part 4.

List name of substance in Part 4.

Nb: Only Care does not provide wound care apart from that requiring First Aid. The information gathered will be used to document and handover to the proper sector/healthcare professional.

Describe the wound not listed

e.g. burn, skin tear/laceration, abrasion, sunburn

Indicate how many pressure sores present

Please provide details of any communications in incident details section below

IMPORTANT:

YOU MUST CALL THE OFFICE/CLIENT SERVICE MANAGER WITHIN 24 HOURS OF INCIDENT OCCURING OR BEING IDENTIFIED.

ph: 1300 783 172

PART 3a: CLIENT'S DETAILS - WHO WAS INVOLVED

MaleFemaleUnspecified

Street Address

Street Address Line 2

CityState

Post Code

VictimParticipantWitnessNot applicable

YesNoUnknown/unsureNot applicable

First AidDoctorHospital OutpatientHospital Inpatient

MaleFemaleUnspecified

Street Address

Street Address Line 2

CityState

Postcode

VictimParticipantWitnessNot applicable

YesNoUnknownNot applicable

First AidDoctorHospital OutpatientHospital Inpatient

MaleFemaleUnspecified

Street Address

Street Address Line 2

CityState

Postcode

VictimParticipantWitnessNot applicable

YesNoUnknownNot applicable

First AidDoctorHospital OutpatientHospital Inpatient

PART 3b: STAFF/CARER DETAILS - WHO WAS INVOLVED

Support WorkerInformal SupportOther

Relationship to Client

VictimParticipantWitness

First AidDoctorHospital OutpatientHospital Inpatient

Support WorkerInformal Support

Relationship to Client

VictimParticipantWitness

First AidDoctorHospital OutpatientHospital Inpatient

PART 3c: OTHER PARTIES - WHO WAS INVOLVED

VictimParticipantWitness

First AidDoctorHospital OutpatientHospital Inpatient

PART 4: WHAT HAPPENED?

Include a factual account of the incident.

Describe any immediate support that has been offered/provided to the person with disabilityimpacted by the incident (for example, medical treatment, counselling, access to advocacy,removed source of harm)

Include details of any relevant events prior to incident (e.g. what was the person doing?), things in the immediate environment of incident or condition of the client at time of incident.

List down the effects the incident had on the person/s involved.

List down any measures/steps that you think are relevant in the prevention of the incident.

Manager's Report

Briefly describe what happened at the time of the incident/near miss.

Browse Files

Consider: Update on board report, WHS Issues, Added to Continuous Improvement Register, and Staff Training.

Consider: Update on board report, WHS Issues, Added to Continuous Improvement Register, Corrective Actions taken/to take and Staff Training.

	Minimal	Minor	Moderate	Significant	Severe
Rare
Unlikely
Possible
Likely
Almost Certain

Completed form to be returned to the coordinator and attached to the client's file.

Incident/Accident Report

Investigation Team

Description of Event