Holistic Healthcare
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FORM-46-Incident Investigation Provider

Incident Investigation Report Form

In-Depth Investigation, Root Cause Analysis, Corrective Actions, and Acknowledgement.

Instructions & Record Storage

This form must be completed by the Clements Johnstone or their delegate. It is used when an incident is considered more serious and requires further in-depth investigation to determine what actions are needed to prevent recurrence.
This includes (but is not limited to) any incident that is notifiable or could lead to litigation (refer to the Incident Management Policy and Procedure).
Where appropriate, people external to the organisation may be invited to participate in the investigation to support an unbiased process.

Record Storage Guidelines

Once the investigation is completed, this form should be stored in the relevant file(s):

  • Participant file: if the incident occurred in connection with NDIS supports/services and has, or could have, caused harm to the participant, or the participant caused serious harm/risk of harm to another person or staff member.
  • Staff file: if a staff member has been harmed or there is a risk of serious harm.

1. Incident Details

Field Details
Name of person/s involved in the incident  
Date of incident (DD/MM/YYYY)  
Location of incident  
Task being performed at the time of incident (e.g. “community activities”)  
What happened? (describe the incident)  

2. Type of Incident

Reportable Incident (NDIS)
(Tick all that apply)		 Non-Reportable Incident
(Tick all that apply)
  • ☐ Death of a participant
  • ☐ Serious injury of a participant
  • ☐ Abuse or neglect of a participant
  • ☐ Unlawful sexual or physical contact with, or assault of, a participant
  • ☐ Sexual misconduct committed against, or in the presence of, a participant
  • ☐ Behaviours of concern
  • ☐ Use of an unauthorised restrictive practice in relation to a participant
  • ☐ Other (specify): ________________________________
  • ☐ Medication error
  • ☐ Property damage
  • ☐ Motor vehicle accident
  • ☐ Aggressive / inappropriate behaviour
  • ☐ Other (specify): ________________________________
  • ☐ Other (specify): ________________________________

3. Preliminary Findings

Field Details
Preliminary findings (summary of what is understood at this stage)  

4. Root Cause Analysis

For each question, indicate Yes / No / N/A and add any relevant comments in the notes box.

Question Yes No N/A
Did the incident occur as part of the involved person’s normal activities? ☐ ☐ ☐
Had a risk assessment been undertaken for this activity/task? ☐ ☐ ☐
Are there documented procedures for this activity? ☐ ☐ ☐
Were these procedures followed? ☐ ☐ ☐
Was appropriate PPE used? ☐ ☐ ☐
Was the involved person trained/competent in this activity? ☐ ☐ ☐
Did a known behaviour problem contribute? ☐ ☐ ☐
Was there a known behaviour support plan? ☐ ☐ ☐
Was the behaviour support plan followed? ☐ ☐ ☐
Did the work / service environment contribute to the incident? ☐ ☐ ☐
Field Details
Details of root cause analysis (underlying causes, contributing factors, system issues, etc.)  

5. Corrective Actions (CA)

Field Details
Description of Corrective Action(s) (what will be done to eliminate/mitigate the root cause)  
Responsible person (Full Name & Position Title)  
Deadline (DD/MM/YYYY)  

(Add extra rows if multiple corrective actions are required.)

6. Corrective Action Implementation Review

Field Details
Findings (has the corrective action been implemented? Was it effective?)  
Completed on (DD/MM/YYYY)  
Status ☐ Open     ☐ More action required     ☐ Closed effectively
Comments  

7. Outcomes

(Tick all that apply and add notes if required)

  • ☐ Completed staff training
  • ☐ New procedure created
  • ☐ Reviewed policies and procedures
  • ☐ Internal audit scheduled
  • ☐ Performance reviews scheduled
  • ☐ Risk assessment completed
  • ☐ Other (specify): __________________________________

8. Completion Checklist

  • ☐ Incident details fully completed by the worker/person involved
  • ☐ Relevant supervisor or line manager involved in the investigation
  • ☐ Incident debriefing conducted by relevant supervisor/manager
  • ☐ Incident Register updated / completed
  • ☐ Incident Investigation Form fully completed and stored in the correct file(s)
  • ☐ Feedback provided to participant/worker and others involved (as appropriate)

9. Sign Off (Investigator / Provider Representative)

Field Details
Full Name  
Position Title  
Signature  
Date (DD/MM/YYYY)  

10. Acknowledgement – Participant / Representative / Staff

Participant / Participant’s Representative / Staff Member (subject to this incident report)

Field Details
Name  
Role (Participant / Participant’s Representative / Staff member)  
I confirm that I have been engaged and informed of the details of the investigation and I am satisfied with the outcome; I have received a copy of this report.
Signature  
Date (DD/MM/YYYY)  

Staff Member (if separate acknowledgement is needed)

Field Details
Name  
Position  
I confirm that I have been engaged and informed of the details of the investigation and I am satisfied with the outcome; I have received a copy of this report.
Signature  
Date (DD/MM/YYYY)