INCIDENT REPORT

CONFIDENTIAL DOCUMENT

In the event of an incident, this report must be completed and submitted as soon as possible, and within 24 hours of the incident occurring

Name of person submitting report (First name and initials of last name only) *

Role:

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 (Address or description):

Participant involved:

Staff | Support Worker involved (First name and initials of last name only):

Third parties involved (if any):

TYPE OF INCIDENT

REPORTABLE INCIDENT

Physical Harm

Serious injuryPhysical assault — alleged or confirmedUnreasonable use of forceSelf-harm resulting in injury

Sexual Harm

Sexual assault — alleged or confirmedInappropriate sexual conductSexual grooming

Abuse, Neglect and Exploitation

Abuse — physical, emotional, or psychologicalNeglect — failure to provide necessary careFinancial coercion or stealing

Restrictive Practices

Unauthorised restrictive practiceAuthorised practice used incorrectly

Safety and Whereabouts

Unexplained absence / elopement

Death

Death of a participant

Other:

DESCRIPTION OF INCIDENT

What happened? *

Describe the incident in factual, objective terms. Include: what happened, how it was identified, sequence of events, and observed consequences. Use first-person where relevant. Avoid opinion or blame.

What was the likely cause?

Include contributing factors, environmental conditions, process failures, human factors etc as applicable.

What was the impact on the participant / others involved?

Include physical, emotional, social and financial impact. Note if harm was sustained or potential/near miss.

Were any physical injuries sustained?

Yes NoUnknown at time of report

If yes — describe nature and location of injury

e.g. Bruising to left forearm; laceration to scalp; fracture to right wrist

IMMEDIATE RESPONSE ACTION

Describe immediate actions taken *

Detail all actions taken immediately after the incident was identified - e.g. first aid, emergency services called, participant reassured, supervisoer notified, environment secured etc.

Was first aid provided?

YesNoNot applicable

Were emergency services called?

YesNoNot applicable

Has the manager been notified by Worker of incident?

YesNo

Has the participants family/guardian been notified by Worker of incident?

YesNoNot applicable

Any additional evidence provided?

Browse

Upload and photographs, reports, witness statements as relevant

CONFIRMATION

I confirm that the information I have provided in this report is accurate and complete to the best of my knowledge at the time of writing.

I understand that this report may be used to support the safety and wellbeing of the people we care for, and may be shared with relevant regulatory bodies where required.

I understand that it is my responsibility to report honestly, and that leaving out important information — whether intentional or not — can affect the safety of others.

Signature:

Draw signature|Type signatureClear

Date signed: