Incident Investigation Form

Is this an incident or accident?

incidentaccident

Administration details

Reportable incident

YesNo

NDIS Commission advised

YesNo

Name of person responsible to report to NDIS Commission

Report date

Incident report type

Incident number

Date

Section 1 – Details of the incident

Date of incident

Place of incident

Who was incident reported to

Describe the incident

Names of the person/s involved in the incident (specify if they are participant, staff or visitor)

If participant involved, add valid NDIS number

Detail the injuries sustained (identify each person and their injuries separately)

Detail the impact on the person/s involved

Support provided to person

Consultation and input from person to provide clarity on incident and input into corrective action and processes

What were the staff member/s, visitor/s or participant/s doing when the incident occurred?

Section 2 – Witnesses to the incident

1. Name and designation

1. Contact details

2. Name and designation

2. Contact details

3. Name and designation

3. Contact details

Section 3 – Administration Information (if hospitalisation was required)

Person incident involved

Date of birth

Sex

Contact person details

Date of admission

Diagnosis on admission

Supports provided

Section 4 - Contributing Factors

Work backwards from the final event to identify the contributing factors of the incident. This process will assist in formulating recommendations for preventative action.

1. What was the sequence of events that led to the critical incident?

2. What was the sequence of events that led to the critical incident?

3. What was the sequence of events that led to the critical incident?

4. What was the sequence of events that led to the critical incident?

5. What was the sequence of events that led to the critical incident?

6. What was the sequence of events that led to the critical incident?

7. What was the sequence of events that led to the critical incident?

Outline identified operational problems – procedure, staff training. Provide ideas for reducing or eliminating this in the future.

Section 5 – Investigation

Investigating officer name

Investigating officer title

Signature

Draw signature|Type signatureClear

Consultation with Participant/advocate /family

Outcome of consultation with witnesses

Outcome of consultations with staff

Section 6 – Recommendations

Consider each of the following:

Could the incident have been prevented?
How well was the incident managed?
Remedial action – prevention or elimination
Who needs to be notified of the incident?
Are recommendations considered to be acting fairly in administrative decision making

Recommendations One

Recommendations Two

Recommendations Three

Recommendations Four

Recommendations Five

NOTE: All Reportable Incidents must have a Risk Assessment completed for the incident.

That risk assessment, any other relevant completed risk assessments, records of staff interviews and any other supporting documentation are to be kept with this form.

Section 7 – Corrective Action Plan

1. Issue

1. Action

1. By whom

1. By when

1. Outcome

2. Issue

2. Action

2. By whom

2. By when

2. Outcome

3. Issue

3. Action

3. By whom

3. By when

3. Outcome

4. Issue

4. Action

4. By whom

4. By when

4. Outcome

5. Issue

5. Action

5. By whom

5. By when

5. Outcome

Section 8 – Referrals

Referred to:

Date referred to Supervisor

Date referred to Manager

Date referred to Participants Person for notification

Date referred to Participants General Practitioner

Management meeting date

Date referred to employees next of kin

Referred to other Departments (e.g. Public Health Unit, NDIS, Coroner)

Department Referred to:

1. Name of person spoke to

1. Date referred

1. Comments

1. Next action

2. Name of person spoke to

2. Date referred

2. Comments

2. Next action

Office use:

Participant given copy of findings

YesNo

Recorded in Incident Register

YesNo

Date Recorded in Incident Register

Date final report due (if required)

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