Incident Report Form

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This Incident Report Form should be completed in relation to all Incidents. The objective of the form is to identify facts
and modify management systems to prevent a recurrence. It is critical not to attribute blame.

1. Fact Finding (to be completed at the scene of the incident)

Incident Manager

Name

Address

Phone Number

Persons involved in Incident (repeat table if multiple persons involved)

Name

Address

Phone Number

DOB

Persons with disability affected by the Incident (repeat table if multiple persons with disability involved)

Name

Address

Phone Number

DOB

Persons with disability affected by the Incident (repeat table if multiple persons with disability involved)

Name

Address

Phone Number

DOB

Workers involved in Incident (repeat table if multiple Workers involved)

Name

Address

Phone Number

Witnesses (repeat table if multiple witnesses)

Name

Address

Phone Number

Incident Details (to the extent known)

Date of Event (or if unknown, date first identified)

Time (or if unknown, time first identified)

Place where Incident occurred

Description of the Incident including the impact on, or harm caused to, any person with disability affected by the Incident

Who has information on events prior to the incident (if applicable)?

Who assessed the risks involved in the Incident (if applicable)?

Who was responsible for implementing risk controls (if applicable)?

Who checked the safety of surroundings and equipment prior to the Incident occurring (if applicable)?

What immediate actions were taken in response to the Incident, including actions taken to ensure the health, safety and wellbeing of persons with disability affected by the Incident

Was the family and/or primary carer contacted?

Was the Incident reported to police or any other body? If so, please include date and time of report

Were medical personnel contacted?

Other actions taken

Is this a Reportable Incident (or alleged Reportable Incident)

If this is a Reportable Incident, the date the Reportable Incident was reported to the NDIS Commission and other relevant external bodies (include the names of the such external bodies)

2. Incident Investigation (to be completed after the facts have been gathered)

(a) The Incident Manager is responsible for conducting an initial assessment of any Incident, to determine the severity of an Incident and to establish the need for, and scope and nature of, an investigation.

(b) If an Incident is a Reportable Incident, an internal investigation must take place.

c) The Incident Manager or an external investigator may wish to (but is not required to) follow some or all of the process recommendations set out in the Assessment, Investigation and Resolution Memorandum when conducting an investigation.

(d) Findings from the investigation should be summarised in this section of the Incident Report Form.

(e) It is expected that further information and/or an external report related to the Incident investigation including records of phone conversations, emails, documents and, where possible, records of face to face interviews will be collected (and not included in this form).

(f) Such information should be recorded and kept by HELPU Support Services in strict confidence in
accordance with the Incident Management and Reporting Policy.

Investigator Details

Name

Address

Phone Number

Findings in relation to how the incident occurred
(list steps that led to the incident or refer to external report)

Findings in relation to how the Incident impacted on, or cause harmed to, any person involved (including persons with disability)?
(list effects of the incident or refer to external report)

List possible contributing factors (refer to following table of potential contributing factors)

(This list provides the more common contributing factors; it is not an exhaustive list.)

List all essential contributing factors. Essential Contributing Factors are those that satisfy the question “Would the incident have still occurred if this factor had not been present?”

Preventative and corrective actions

Report in relation to preventative and corrective actions

How could the incident have been prevented?

Any organisational issues that may have contributed to or did not function in preventing an Incident?

Refer to the Hierarchy of Control below and the following list of preventative / corrective actions.

3. Preventative and Corrective Action to be taken

(a) What changes and corrective action can HELPU Support Services make in order to prevent further Incidents from occurring (if any)?

(b) In particular, describe the action necessary to eliminate or control the essential contributing factors identified and use the Hierarchy of Control below.

Hierarchy of Control

1. ELIMINATION
Can another work method or piece of equipment be used, hence eliminating this hazard?

2. SUBSTITUTION
Can the hazard source be replaced with less hazardous equipment, materials or processes

3. ENGINEERING CONTROLS
eg. Ventilation of confined spaces or other areas

4. ADMINISTRATIVE CONTROLS
eg. Worker rotation, Worker dismissal, hiring procedures, safe work procedures, inspections/audits.

5. PERSONAL PROTECTIVE EQUIPMENT
eg. Respiratory protection, safety harnesses, safety glasses/goggles, gloves.

4. INCIDENT RESOLUTION WITH RESPECT TO PERSON(S) INVOLVED

In addition to Preventative/Corrective Action, HELPU Support Services could undertake remedial action
proportionate to the severity of the Incident, including but not limited to:

(a) providing an apology;

(b) disciplinary action; and

(c) other remedial action deemed appropriate in the circumstances based on advice obtained by HELPU Support Services (where appropriate)

REMEDIAL ACTION

Responsibility

Completion Date

REMEDIAL ACTION

Responsibility

Completion Date

REMEDIAL ACTION

Responsibility

Completion Date

REMEDIAL ACTION

Responsibility

Completion Date

What actions should be/were taken to support or assist persons with disability affected by the Incident

5. CONSULTATION

The Incident Manager will consult Clients (including persons with disability), family and advocates at regular intervals in connection with the management, resolution and any decision in relation to the Incident. In addition, such consultation(s) will involve obtaining the Client’s views in relation to the Incident.

Consultation (repeat table if multiple persons consulted with)

Date of consultation

Person consulted

Have these persons been provided with any reports/findings regarding the incident

Whether the person believes the Incident could have been prevented?

What could we have done instead?

How else could we have done it?

How well the person considers the Incident was managed and resolved?

Whether the person considers that other persons or bodies need to be notified of the Incident?

6. CONTINUOUS IMPROVEMENT

The Incident Manager should obtain the feedback of appropriate Workers in connection with the Incident
management procedure to ensure that it remains relevant and continues to reflect the actual manner in which
Incident Management activities are undertaken.

Worker Feedback (repeat table if multiple persons provided feedback)

Date of feedback

Worker consulted

Have these Workers been provided with any reports/findings regarding the incident

Any organisational issues that may have contributed to or did not function in preventing an Incident?

How could the Incident Management procedures/resolution procedures be improved

How can better service/product design help?

How can we control failure moving forward (minimize consequences)?

Other comments

Checkboxes

This Incident Report Form is true and correct in every material particular.

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