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Contact Info

  • 1800 953 997
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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
Part of body injured (mark below with circle):
Mechanism of injury (tick one):
Nature of injury:

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
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About Us

As a Registered NDIS provider, Cosmos Divine Care provides services in a unique manner. Every participant receives a personalized approach and our services are tailored to meet the needs of each individual.

The Cosmos Divine Care team acknowledges the traditional owners and custodians of the country throughout Australia. We acknowledge their continuing connection to land, sea, and community. Respect is expressed to the people, the cultures, and the elders past, present, and emerging.

Contact Info

Office (by Appointments Only)

  • 40 Le Page Run, South Morang, 3752 Victoria
  • 1800 953 997
  • info@cosmosdivinecare.com.au

Further Information
What is NDIS?
Support Network - Ask Izzy
About COVID-19
NIDS Pricing

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