Incident Report

Participant and Contact Information

Name of the person completing this formif not the NDIS participant

Participant’s Full Name *

NDIS Number *

Date of Birth *

Mobile Phone *

Email *

Is there an alternative contact person?If yes, please provide their full name

What is their relationship to the participant?

Parent / Legal GuardianSpouse / PartnerFamily Member / FriendNDIS ProviderOther

Alternative contact phone number

Alternative contact email address

Incident Details

What date did the incident occur?

Who was involved in the incident?Include full names and contact details

Who witnessed the incident?Include full names and contact details

What happened in the lead up to the incident?

What happened during the incident?

What happened immediately after the incident?

Was anyone injured?

Was medical attention required?

Was any property damaged?

Is an insurance claim required?If so, please provide details of the insurance holder and type of insurance

Do you have any documents or photos to include?

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Reporting Requirements

Does any other person or organisation need to be notified?

Yes - NDIS providerYes - PoliceYes - NDIS Quality & Safeguards CommissionYes - Child & Youth Protective ServicesYes - Family Member of participantYes - Senior PractitionerYes - Regulating Body (e.g. AHPRA)NoOther

Provide details of these reports

Actions to Take

What actions need to be taken to ensure the safety of those involved in the incident?

Has a risk assessment been done to prevent the incident recurring?

Who needs to be notified of the outcome of the risk assessment?

When were they notified?

Any additional information?

Review

What has happened in the time following the incident?

Is there any additional information you have now, that you didn't have earlier?

Signature of the person completing this form *

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Date *

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