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Incident Report Form
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Incident Report Form
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
(Required)
First
Last
Address
(Required)
Phone
(Required)
Email
(Required)
Persons involved in Incident (repeat table if multiple persons involved)
Name
First
Last
Address
Phone
DOB
Email
Persons with disability affected by the Incident (repeat table if multiple persons with disability involved)
Name
First
Last
Address
Phone
DOB
Email
Workers involved in Incident (repeat table if multiple Workers involved)
Name
First
Last
Address
Phone
Email
Witnesses (repeat table if multiple witnesses)
Name
First
Last
Address
Phone
Email
Incident Details (to the extent known)
Date of Event (or if unknown, date first identified)
MM slash DD slash YYYY
Time (or if unknown, time first identified)
Hours
:
Minutes
AM
PM
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 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?
Were medical personnel contacted?
Other actions taken
Is this a Reportable Incident (or alleged Reportable Incident)
Yes
No
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)
Date included in the Incident Register
2. INCIDENT INVESTIGATION (TO BE COMPLETED AFTER THE FACTS HAVE BEEN GATHERE)
(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 Devote Care in strict confidence in accordance with the Incident Management and Reporting Policy.
Investigator Details
Name
First
Last
Address
Phone Number
Email
Findings in relation to how the incident occurred
(list steps that led to the incident or refer to external report)
1
2
3
4
5
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)
1
2
3
4
5
List possible contributing factors (refer to following table of potential contributing factors)
1
2
3
4
5
(This list provides the more common contributing factors; it is not an exhaustive list.)
ENVIRONMENT
Slippery surface
Rough terrain
Dust/particles
Fumes
Fibres
Liquid or chemical
Mist
Noise
Heat
Rain
Low light levels
Fungi
Bacteria
Virus
Insects
Radiation solar
Radiation other
Mud
DESIGN
Equipment
Vibration
Posture
Force (kg)
Weight (kg)
Machinery
Layout
Protective equipment
Tools
Guarding
Plant
Furniture
Material
Substance
SYSTEMS
Written job procedures
Training (induction)
Supervision Instruction
Maintenance
Storage or stacking
Policy/manuals
Housekeeping
Hazard detection
Licences
Endorsements
Hours of work
Work demands
Movement
Repetition
Required equipment
available
HUMAN
Inexperience
Fatigue
Understanding
Procedures
Followed Disability
MisconductInattention
Illness
Relationship
Language
Lifestyle Reflex
action
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?”
1
2
3
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?
How could the injury/harm have been avoided?
How can better service/product design help?
How can we control failure moving forward (minimise consequences)?
Other comments
Refer to the Hierarchy of Control below and the following list of preventative / corrective actions.
Change to induction
training
Equipment/machinery
modifications
Change to work
environment
Worker dismissal
Change to ongoing
training
Change to work
procedures
Equipment / machinery
maintenance
Other preventative
action
3. PREVENTATIVE AND CORRECTIVE ACTION TO BE TAKEN
(a) What changes and corrective action can Devote Care 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.
1. PREVENTATIVE/CORRECTIVE ACTION
1. Responsibility
1. Completion Date
MM slash DD slash YYYY
2. PREVENTATIVE/CORRECTIVE ACTION
2. Responsibility
2. Completion Date
MM slash DD slash YYYY
3. PREVENTATIVE/CORRECTIVE ACTION
3. Responsibility
3. Completion Date
MM slash DD slash YYYY
4. PREVENTATIVE/CORRECTIVE ACTION
4. Responsibility
4. Completion Date
MM slash DD slash YYYY
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, Devote Care 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 Devote Care (where appropriate)
1. REMEDIAL ACTION
1. Responsibility
1. Completion Date
MM slash DD slash YYYY
2. REMEDIAL ACTION
2. Responsibility
2. Completion Date
MM slash DD slash YYYY
3. REMEDIAL ACTION
3. Responsibility
3. Completion Date
MM slash DD slash YYYY
4. REMEDIAL ACTION
4. Responsibility
4. Completion Date
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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 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
MM slash DD slash YYYY
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 (minimise consequences)?
Other comments
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1300 300 999 │
info@devotecare.com.au
Who We Are
How We Can Help
Support Coordination
Transport and Travel Assist
Domestic Assistance
Assistance with Daily Life Tasks
High Intensity Activity Support
Community Nursing Care
Community Participation and Social Support
Assist with Life Stage Transition
Supported Independent Living
Group Based Centre Activities
Getting Started
Blog
Client Stories
Contact Us
Referral Form
Portal Login
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