Incident Report
In the event of an incident, this report will need to be completed as soon as possible and given to the immediate supervisor of the worker completing this report.
Name of person completing report:
Phone:
Date:
Details of incident
Date of incident: (or if not known, first identified)
Time of incident: (or if not known, first identified)
Location of Incident:
Type of Incident:
Abuse/Assault
Breach of privacy
Behaviour (of concern)
Death
Injury
Medication
Poor quality of care
Property damage
Restrictive practice (unauthorised)
Near Miss
Other: (include details)
Who was involved?
Answer; full name, phone number, worker/client/witness, injured person.
What happened?
(Describe briefly: What happened? How the incident was identified? Possible cause? Impact to people involved? Who (if any) were harmed? What was the extent of the harm?
Immediate actions taken
(Include details of actions taken to ensure the health, safety and wellbeing of the individuals affected by the incident, e.g. first aid; reported to police; ambulance called; emotional support; meeting participant's needs; etc.)
Confirmation of completing person
I hereby confirm that the information provided in this report is accurate to the best of my knowledge:
Signature:
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Date signed:
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