Incident Report Form

Reporting Person First Name

Reporting Person Last Name

Reporting Person Phone Number *

Reporting Person Email Address *

Date of Incident

Time of Incident

Injured Person's Full Name

Injured Person's Phone Number

Injured Person's Email Address

Were there any witnesses to the incident?

Yes

Witness Full Name

Witness Phone Number

Witness Email Address

Witness description of the incident

Does the incident involve:

the death of a person

serious injury of a person

abuse or neglect of a person

unlawful sexual or physical contact with, or assault of, a person with disability

sexual misconduct against, or in the presence of, a person with disability, including grooming a person for sexual activity

use of a restrictive practice that is unauthorised by the participant's state or territory, or does not follow a behaviour support plan for the person with disability

None of the above

Unsure

Description of the incident - please provide as much detail as possible:

Description of injuries or impact on the person (if applicable)

What actions have been taken? (e.g. first aid applied, ambulance called, support rendered)

Any other information you would like to provide:

What happens from here?

Once you submit this form, our team will be notified that an incident has occurred. Depending on the type of incident, we may need to report this to the NDIS Commission. Our team may contact you, the participant, or any other people involved in the incident as part of the investigation. We'll work with you, the participant and other involved people to determine what corrective actions can be undertaken to prevent the incident from recurring.