INCIDENT REPORT FORM

Details of Reporting Person

Name

Position:

Contact Phone Number:

Client Details

Client Name:

Client DOB:

Client Address:

Incident Details

Date of Incident

Time of Incident

Location of Incident

Description of incident

Use dot points

Nature of the Incident Tick all that apply:

Tick all that apply:

Physical injury or harm

Medical emergency (e.g., seizure, allergic reaction)

Behavioral incident (e.g., aggression, self-injury, property destruction)

Environmental incident (e.g., trip, fall, equipment malfunction)

Medication-related incident Property damage

Near miss (no injury, but potential risk present)

Other (Please specify)Other (Please specify)

Details of Injury or Harm

Yes

Details of Injury or Harm (if applicable)

Type of injury or harm:

Part of the body affected:

Severity

Minor (no medical attention required)

Moderate (medical attention needed but no hospital visit)

Severe (hospital visit or emergency admission)

Was medical attention provided?

Yes

If yes, specify details:

Immediate Actions Taken

First aid administered?

Yes

Support provided to participant:

Support strategies used: (e.g., calming techniques, redirection)

Emergency services contacted?

Yes

If yes, which service?

Time contacted:

The scene or situation made safe?

Yes

Follow-up Actions & Preventative Measures

Investigation or review required?

Yes

If yes, specify:

Recommended follow-up actions:

Name of Support Worker

Signature

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Location

Time Operasional

Details of Reporting Person

Client Details

Incident Details

Nature of the Incident Tick all that apply:

Details of Injury or Harm (if applicable)

Immediate Actions Taken

Follow-up Actions & Preventative Measures

Our Address

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