Disability Services & Support Provider in Perth, Western Australia | Hale Foundation
Date :
Initiator:
Incident Report no.:

PART A : To be completed by the Authorised Notifier

1. LOCATION & TIME DETAILS OF INCIDENT / ACCIDENT

Date of Incident :
Time of Incident (AM/PM):
Area:
Exact Location of Incident :
Street :
Suburb :
State :
Person Reporting :
Contact Number :

Status

2. DESCRIPTION OF INCIDENT (Attach further information if required)

Give a full description of the incident:

How was the injury or damage sustained? (e.g. slipped on wet ground)

3. NATURE OF INCIDENT

Other

Immediately report any incident where the yellow box to NDIS Commission is ticked. For more information, read below:

The following incidents (including allegations) arising must be reported to the NDIS Commission:

  • The death of an NDIS participant
  • Serious injury of an NDIS participant
  • Abuse or neglect of an NDIS participant
  • Unlawful sexual or physical contact with, or assault of, an NDIS participant
  • Sexual misconduct committed against, or in the presence of, an NDIS participant, including grooming of the NDIS participant for sexual activity
  • The unauthorised use of a restrictive practice in relation to an NDIS participant

4. INJURY INFORMATION (If more than one add more sheets)

Name :
Sex :
Birth Date :
Phone :
Job Title :

Status

Body Part :

Other:

Nature of Injury :

Other:

Caused by:

Full name of first Aider (if applicable):

Description of first aid treatment :

5. PROPERTY DAMAGE (Including environmental impacts)

Description of Damage

6. WITNESSES (Attach copies of witness statements - supported file PDF only)

Name :
Phone Number:
Name :
Phone Number:

PART B To be completed by Supervisor or safety representative

1. SUPERVISOR

Name :
Date Received :
Position :
Time Received (AM/PM):
Phone :
Mobile :

2. WHAT FACTORS CONTRIBUTED TO THE INCIDENT (Root cause and contributing factors)? (Mark all that apply, describe most significant factors)

Supervision :
Training & Competence :
Work Procedures :
PPE :

Other

3. CORRECTIVE ACTIONS (What has been done to correct the situation? – short term fix)

4. PREVENTION STRATEGY (What actions can be taken to reduce the risk of reoccurrence? – long term fix)

PART C

1. NOTIFICATIONS

Date Report Received :
Time Received (AM/PM) :
Notifiable Incident? (yes/no) :
Authority Notified :
Date Notified :
Time :
Authority Officer/Record :
Incident Investigated By :
Copy to HR? :
Dated :

2. INCIDENT CLASSIFICATION

3. ACTION PLAN (What systemic actions need to be put in place to prevent a recurrence?)

Specific Action Required Person / Position Responsible Target Date

4. DOES THE RISK ASSESSMENT NEED TO BE REVIEWED AS A RESULT OF THIS INCIDENT?

(Risk assessment to be completed in consultation with contractor/s and other parties involved)

PART D - REVIEW OF THE INCIDENT by Managing Director/ Management Team

Name :
Date :

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