NSWDC Incident Report
To report an incident, please provide the following information
Work Location
Organisation/ Facility
In the Community
Client Home
Other
Date and time incident was reported:
*
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and time when incident actually occurred:
*
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident:
Activity engaged at the time of Incident
Type of Incident
Please Select
Hazard/Near Miss
Injury
Incident
Hospital
Who was involved in the Incident? (Participant, etc.)
First Name
Last Name
Date of Birth (Participant, etc.):
-
Day
-
Month
Year
Gender (Participant, etc.)
Please Select
Male
Female
other
Address (Participant, etc.):
Street Address
Street Address Line 2
City
State / Province
Postcode
Participant NDIS Number (if known)
Details of Staff:
Staff Name
First Name
Last Name
Staff Address
Street Address
Street Address Line 2
City
State / Province
Post Code
Staff Phone Number
Please enter a valid phone number.
Staff Email
example@example.com
Staff Employment Status
Please Select
Casual
Full Time
Permanent PT
Contractor
Other
Was there anyone else involved in the incident?
Incident details
*
Describe how and what happened. Include detailed description, characteristic, colour, and size of injury(ies) noted. Please refer to body mapping image below to indicate specific area of injury (numbered). Use a separate sheet if necessary. Please include car registration number if reporting a motor vehicle accident).
File Upload (photos, document, video, etc.)
Browse Files
Drag and drop files here
Choose a file
Please upload photo(s) or video(s) of the incident.
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of
List details of any witness & include contact details.
Cause of Injury
Death of a Participant
Serious injury to the participant
Abuse
Neglect
Sexual Misconduct
Physical Assault
Unauthorised use of restrictive practice
Vehicle Accident
Behaviour of Concern of the participant
Psychological stress/ Bullying/ Harassment
Exposure to hazardous substances
Fall/ Minor Injury
Other
Was a report of the incident notified to any one else (management, family, etc.)?
Was First Aid provided?
Please Select
Yes
No
Not applicable
First Aiders Name
First Name
Last Name
Signature
Tick all that apply
Did the incident occur as part of the involved person's normal activity
Did equipment contribute
Had a risk assessment been undertaken
Are there documented safe work procedures followed
were the manual handling procedures followed
was appropriate PPE used
Did a known behaviour contribute
Was a Behaviour support plan in place and followed
Did poor house keeping contribute
Did the work environment contribute
Name of staff/person completing the form:
First Name
Last Name
Signature of staff/person completing the form:
The following section to be completed by Management
After reviewing the above prompts and thorough interviews/site visits, what are the identified cause/s?
Remedial actions recommended:
Conduct risk assessment
Re-instruct persons involved
Debriefing/ councelling
Improve communication
Improve work environment
Request maintenance
BSP review
Temporarily relocate employees involved
Investigate safer alternatives
Develop and / or provide training
Other
What has been implemented or planned to prevent recurrence:
Did the injured person stop work
Please Select
Yes
No
Not Applicable
If Yes, Date
-
Day
-
Month
Year
Date
OUTCOME:
Treated by Doctor
Lodged workers compensation claim
Contacted by RTW Coordinator
Work cover notified
Hospitalised
Returned to normal duties
Returned to modified duties
Management Person:
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Email
example@example.com
Further General Comments
Report Now!
Should be Empty: