Incident Report

INSTRUCTIONS – To be completed by the worker, supervisor or manager at the time.

PART A: INCIDENT DETAILS

Name of person completing Incident Report: *

Date of Incident: *

Time of Incident *

Class of Incident: *

Class 1: Death, Permanent Disability

Class 2: Temporary Disability, Medical /Hospital Treatment, Lost Time Injury (LTI)

Class 3: Notifiable incident to SafeWork NSW or NDIS (Serious injury of person with a disability, Medication error, Abuse or neglect of a person with a disability, Unlawful sexual or physical contact with or assault of a person with a disability, Sexual misconduct, Use of restrictive practice)

Class 4: Minor Injury, First Aid Injury, Property Damage, Motor vehicle accident, Physical / Verbal abuse, Psychological

Class 5: Near Miss / No immediate injury / Behaviour

Class 6: Allegation

Address / Location of Incident: *

Details of Person/s involved:

Name

Phone Number

Participant

Support Worker

Other staff

Member of Public

Name

Phone Number

Participant

Support Worker

Other staff

Member of Public

For an Allegation - Details of Person/s making the record of alleged incident:

Name

Phone Number

Witnesses or Other Support Workers on shift (If Applicable):

Name

Phone Number

Other

Details of how incident occurred: (Attach additional pages and photographs as required) *

Choose File

PART B: INJURY DETAILS

PART C: RECORD OF TREATMENT

Other

Comments:

Name of First Aid Officer:

Date

**PART D: RETURN TO WORK COORDINATOR (if required)**

Return to Work Coordinator Contacted:

Yes

No

Not Applicable

Name of RTW Coordinator:

Date

PART E: MANAGER REVIEW

Management Comments:

Name

Date

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Incident Report

PART A: INCIDENT DETAILS

PART B: INJURY DETAILS

PART C: RECORD OF TREATMENT

**PART D: RETURN TO WORK COORDINATOR (if required)**

PART E: MANAGER REVIEW

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