Incident Form

INCIDENT INVESTIGATION

Create your Incident numbere.g. 06JAN23RF - this means that this incident occurred on the 6th of January 2023 by Rose Farfalla

Name of Reporter

Date of Incident

Time of the Incident

Name of the person/s involved in the incidentSpecify whether they are staff, participant, visitor or other.

Place of the incident

Date of Birth if known

Is this a reportable incident?

YesNo

What’s an NDIS reportable incident? The incident management system must include procedures for identifying, assessing, recording, managing, resolving and reporting incidents. Certain incidents must be notified to the NDIS Commission as reportable incidents, including the death, serious injury, abuse or neglect of a person with disability and the unauthorised use of restrictive practices. These incidents must be reported to the NDIS Commission. The following incidents (including allegations) arising in the context of NDIS supports or services must be reported to the NDIS Commission: the death of an NDIS participant serious injury of an NDIS participant abuse or neglect of an NDIS participant unlawful sexual or physical contact with, or assault of, an NDIS participant sexual misconduct committed against, or in the presence of, an NDIS participant, including grooming of the NDIS participant for sexual activity the unauthorised use of a restrictive practice in relation to an NDIS participant.

Who witnessed the incident?

What were staff members, visitors or participants doing at the time of the incident?

What was the sequence of events that led to the incident?Please work backwards from the final event to identify the factors that contributed to the incident.

Detail the injuries sustained and how they were managedIdentify each person separately

Do you, the person whom this incident occurred to, feel further medical and/or non-medical assistance is needed? If so, please contact HappinessFirst managemente.g. doctor, counselling

The incident will be followed up by the Incident Management Team within the next 24 business hours. Provide your contact information or that of who you'd like to act as advocateProvide name and contact number

Signature of person who this incident affects

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Signature of person filling in this form, if different

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Further information provided by HappinessFirst Management:

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