• Incident/Accident Report

    Incident/Accident Report

  • Date submitted:
     / /
    2 digit day, 2 digit month, 4 digit year :

  • PART 1: REPORTER DETAILS


  •

  • PART 2: INCIDENT DETAILS

  • Were you around when the incident happened?
  • Did it occur during shift work?

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

  • Date
     / /
    2 digit day, 2 digit month, 4 digit year
  •  :
    • Incident Subcategory Start 
    • Type of Breach of privacy/confidentiality matters
    • Medical attention 
    • Was medical attention suggested?
    • WHS Section collapse 
    • What was the accident/hazard?

    • Other type of Wound 
    • Accidental Wound 
    • Pressure Injury start 
    • Image 1
    • Location of Pressure sore/s
    • Image 2
    • Moisture Associated Skin Damage 
    • Image field 237
    • Moisture Associated Skin Damage END 
    • Was the police or emergency services contacted?*
    • WHS - Worker affected? Did this incident impact your health, safety, or well-being, or cause an injury to you?*

    • Was the office/client manager contacted prior to completing this report?*

    • 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

  • Gender*
  • Was the person the:*
  • Was the person injured?*
  • Was medical attention required?*
  • Type of medical attention*
  • Gender*
  • Was the person the:*
  • Was the person injured?*
  • Was medical attention required?*
  • Type of medical attention*
  • Gender*
  • Was the person the:*
  • Was the client injured?*
  • Was medical attention required?*
  • Type of medical attention*

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

  • Was it a Support Worker or Informal Support (e.g. family member)?*

  • Was the person a:*
  • Was the person injured?*
  • Was medical attention required?*
  • Type of medical attention*
  • More than 1 person?
  • Was it a Support Worker or Informal Support (e.g. family member)?*
  • Was the person a:*
  • Was the person injured?*
  • Was medical attention required?*
  • Type of medical attention*
  • Was there any other party/parties involved?*
    • 3c - Other Parties 

    • PART 3c: OTHER PARTIES - WHO WAS INVOLVED

    • Was the party the:*
    • Was the party injured?*
    • Was medical attention required?*
    • Type of medical attention*
    • INCIDENT DETAILS SECTION COLLAPSE 

    • PART 4: WHAT HAPPENED?

    • Was there any property/equipment damaged?*
    • PART 5 - MANAGEMENT RESPONSE 

    • Manager's Report

    • Date of Investigation
       / /
      2 digit day, 2 digit month, 4 digit year
    • Date of Incident Occurrence:
       / /
      2 digit day, 2 digit month, 4 digit year
    • Has a similar incident/near miss occurred previously?
    • Was it a notifiable incident?

    • Investigation Team

    • Who are involved in the investigation?

    • Description of Event

    • Who was involved in the incident?

    • Browse Files
      Cancelof
    • WHS-related? Did this incident impact worker/s health, safety, or well-being, or cause them an injury?*
    • SECTION COLLAPSE - CONTRIBUTING FACTORS 
    • What factors contributed to the incident?

    • Environment:

    • Due Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Completion Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Equipment/Materials

    • Due Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Completion Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Work Systems:

    • Due Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Completion Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • People:

    • Due Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • Completion Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • SECTION END - CONTRIBUTING FACTORS 
    • Risk of same/similar incident reocurrence (Y axis = likelihood. X axis = impact)*
      Rows

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

    • End Office use 1 

    • Final Action

    • Was the follow up action completed?
    • Was the issue fixed?
    • Was the incident withdrawn?
    • Date withdrawn:
       / /
      2 digit day, 2 digit month, 4 digit year
    • Date Completed:
       - -
      2 digit day, 2 digit month, 4 digit year
    • Should be Empty: