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Workplace Incident Report Form

Workplace Incident Report Form

Incident details

Date & Time of Incident
Relationship with the Participant
Date of Incident Reporting
Type of Incident

Injury Details

Any physical injury sustained

Notification

Reportable Incident?
NDIS Commission notified?
Immediate notification?
5 Day notification?
Does this incident require to notify other parties (e.g. notifying family/guardian if the participant is a child)?
Does this incident require Police notification (e.g. sexual misconduct etc.)?
Does the severity of this incident require notification to Safe Work?

Treatment

Medically treated?
If yes;
Lost Time Injury (LTI)?

Sign off

Date

Investigation (For Official Use only)

Root causes analysis

Did the incident occur as part of the involved person’s normal activities?
Did equipment contribute?
Was the equipment used designed for activity?
Was the equipment properly maintained?
Did the equipment fail?
Had a risk assessment been undertaken?
Did safety instructions accompany activity?
Are there documented safe work procedures (SWP) for activity?
Were these SWP followed?
Was appropriate PPE used?
Was the involved person trained in this activity?
Did a known behaviour problem contribute?
Was there a known behaviour management plan?
Was behavioural management plan followed?
Did poor housekeeping contribute?
Did the work environment contribute?
Others:

Corrective actions

Deadline

Comments by Director

Completed On
Status:
Outcomes:
Completion Checklist

Sign Off

Acknowledgement
Date Completed