Workplace Incident Report Form

Incident Report Number:

Incident details

Name (Person completing incident form) *

Phone Number *

Date & Time of Incident *

Date of Incident Reporting *

Worker Participant (Self) Participant’s (Friend/Family/Guardian or Advocate) Others

Location of incident *

Witness (1) Name (if applicable):

Phone Number:

Email *

Witness (2) Name (if applicable):

Phone Number: (2)

Email (2) *

Description of Incident *

Type of Incident *

Injury Details

Any physical injury sustained

YES NO

Part of body injured (mark below with circle):

Mechanism of injury (tick one):

Nature of injury:

Notification

Reportable Incident? *

YES NO UNSURE

NDIS Commission notified? *

YES NO UNSURE

Immediate notification? *

YES NO UNSURE

5 Day notification? *

YES NO UNSURE

Does this incident require to notify other parties (e.g. notifying family/guardian if the participant is a child)? *

YES NO

Does this incident require Police notification (e.g. sexual misconduct etc.)? *

YES NO

Does the severity of this incident require notification to Safe Work? *

YES NO

Treatment

Medically treated? *

YES NO

If yes;

First aid Medical or Dental Centre Hospital (Admission) Other

Lost Time Injury (LTI)? *

YES NO

Days Lost:

Details of Action Taken

Sign off

Report signed off by: *

Date *

Signature *

Sign above using mouse or finger

Investigation (For Official Use only)

Preliminary findings:

Root causes analysis

Did the incident occur as part of the involved person’s normal activities?

YES NO N/A

Did equipment contribute?

YES NO N/A

Was the equipment used designed for activity?

YES NO N/A

Was the equipment properly maintained?

YES NO N/A

Did the equipment fail?

YES NO N/A

Had a risk assessment been undertaken?

YES NO N/A

Did safety instructions accompany activity?

YES NO N/A

Are there documented safe work procedures (SWP) for activity?

YES NO N/A

Were these SWP followed?

YES NO N/A

Was appropriate PPE used?

YES NO N/A

Was the involved person trained in this activity?

YES NO N/A

Did a known behaviour problem contribute?

YES NO N/A

Was there a known behaviour management plan?

YES NO N/A

Was behavioural management plan followed?

YES NO N/A

Did poor housekeeping contribute?

YES NO N/A

Did the work environment contribute?

YES NO N/A

Others:

YES NO N/A

Corrective actions

Description of actions:

Person Responsible

Position

Deadline

Comments by Director

Findings:

Completed On

Status:

Open More action required Closed Effectively

Outcomes:

Run training/induction session Review/update risk register Review/amend relevant process/documents Create a new procedure Others:

Completion Checklist

Incident details fully completed by the worker/person involved? Relevant Manager completed and signed? Incident register completed? If Property damage, maintenance request completed? Did the director complete and signed? Is feedback given to participant/worker and others involved?

Sign Off

Investigation completed by:

Date Completed

Acknowledgement

I acknowledge that Participant / Participant’s representative/ Worker, subject to this incident report have been engaged and informed with the detail of the investigation. I am satisfied with the outcome. I have provided & retained a copy of this report as per policy and procedures of Cosmos Divine Care.