Holistic Healthcare
0480 732 743

REP-48-Incident Report Form

Incident Report Form

Incident Report No. (office use): ____________

Instructions

This form should be completed by anyone who becomes aware of an incident or allegation occurring in the course of, or in connection with supports or services provided by Holistic Healthcare Management Services.

The objective of the form is to identify facts and root causes/reasons to prevent a recurrence. It is critical not to attribute blame.

With the information below, Holistic Healthcare Management Services will work with you to investigate and resolve the incident. Please note Holistic Healthcare Management Services takes privacy seriously and will only collect, hold, use and disclose your personal information in accordance with the Privacy Act.

Section A. Impacted Person

Who is the person who was impacted or affected by this incident/allegation? If there is more than one person impacted by an incident, an additional form must be filled in for each person.

First Name:  
Last Name:  
NDIS Number:  
Gender:  
Date of Birth:  
Contact Number:  
Email Address:  
Additional Details:  

Section B. Incident Details

Date of the incident  
If the date is unknown, please explain the reason why. Place N/A if the date was added above  
Time of the incident where applicable of known  
Incident location
Place where the incident occurred with accurate descriptions where applicable.		  
Description of the incident/allegation
Describe any acts, omissions, events or circumstances that occur in connection with our NDIS supports or services provided to a person with disability and have, or could have, caused harm to the person with disability, a staff member or another person.		  
Were there circumstances leading up to the incident/allegation?
Provide as much detail as possible.		  

Section C. Type of Incident

You may wish to select more than one category if the incident/allegation falls into multiple categories

Type of Incident Tick
Medication error ☐
Property damage ☐
Motor vehicle accident ☐
Aggressive/inappropriate behaviour ☐
Other: _____________________________________ ☐

Serious or Reportable Incident

Reportable incidents are serious incidents or alleged incidents which result in harm to an NDIS participant and occur in connection with NDIS supports and services.

Reportable Incident Category Tick
Death of a person with disability ☐
Serious injury or a person with disability ☐
Abuse of a person with disability ☐
Neglect of a person with disability ☐
Unlawful sexual acts/offences ☐
Unlawful physical contact/offences ☐
Sexual misconduct against a person with disability ☐
Unauthorised use of Restrictive Practice ☐
None ☐

Section D. Injury Details

Injury details  
Part of the body injured (mark below with circle), if applicable  
Mechanism of injury
Tick at least one
  • ☐ Falls/trips/slips
  • ☐ Hit by moving objects
  • ☐ Body stress/manual handling
  • ☐ Chemicals/other substances
  • ☐ Mental stress
  • ☐ Hitting objects with part of the body
  • ☐ Sound/pressure
  • ☐ Heat/electricity
  • ☐ Biological factors
  • ☐ Vehicle incident
  • ☐ Other: _____________________________________
Nature of injury
  • ☐ Head/intracranial
  • ☐ Fractures
  • ☐ Laceration/amputation
  • ☐ Internal organ damage
  • ☐ Burns
  • ☐ Injury to spinal cord
  • ☐ Joint/ligament damage
  • ☐ Foreign body
  • ☐ Strain/Pain
  • ☐ Electrocution
  • ☐ Diseases/conditions (details in comments section)
  • ☐ Other: _____________________________________
Comments  

Section E. Subject of allegation

A subject of allegation is a person who has been accused of the incident and may be a NDIS provider worker or another person, for example a resident living in the same house. There may be more than one subject of allegation. If there is not space on this form, please include additional information in an attachment.

First Name:  
Last Name:  
Gender:  
Position Title:  
Date of Birth:  
Contact Number:  
Email Address:  
Additional Details:  

Section F. Another subject of allegation

Only complete this section if there is another person who is a subject of allegation. Otherwise, please place N/A in all questions in this section.

First Name:  
Last Name:  
Gender:  
Position Title:  
Date of Birth:  
Contact Number:  
Email Address:  
Additional Details:  

Section G. Witness

Only complete this section if there is a person who witnessed the incident. Otherwise, please place N/A in all questions in section F.

First Name:  
Last Name:  
Gender:  
Date of Birth:  
Contact Number:  
Email Address:  
Who is this person?
E.g., A support worker from another service provider.		  

Section H. Another witness

Only complete this section if there is another person who witnessed the incident. Otherwise, please place N/A in all questions in section I.

First Name:  
Last Name:  
Gender:  
Date of Birth:  
Contact Number:  
Email Address:  
Who is this person?
E.g., A support worker from another service provider.		  

Section I. Immediate action taken

Only complete this section if there is any immediate action that was taken. Otherwise, please place N/A in all questions in section J.

Have the police been informed of the incident/allegation? ☐ Yes       ☐ No
Officer’s name  
Police station  
Police event number  
If the police have not been informed of the incident/allegation, why not?  
Are the impacted person’s family or guardian aware of the incident? ☐ Yes       ☐ No
If not, why hasn’t the impacted person’s family or guardian been contacted?  
If the impacted person is under 18, has the relevant child protection agency been contacted? ☐ Yes    ☐ No    ☐ Unknown    ☐ Not applicable
If not, why hasn’t the child protection agency been contacted?  
Were medical personnel contacted? ☐ Yes       ☐ No
If not, why were the medical personnel not contacted?  
Describe any immediate support that has been offered/provided to the person with disability impacted by the incident.
For example, medical treatment, counselling, access to advocacy, removed source of harm, etc.		  

Section J. Declaration

To the best of my knowledge, the information provided in this application is true, correct and accurate.

Full Name:  
Signature:  
Date:  

I am submitting as:

  • ☐ You are a NDIS participant making the complaint directly
  • ☐ I am a staff member reporting the incident
  • ☐ You are making the complaint on behalf the NDIS participant or a person with a disability, what is your relationship with the participant? ______________________________________________