Incident Report Form

This form is used to document incidents involving children either under our supervision, during sessions or while they are on site with their adult caregiver under their supervision. This information helps us understand and record their behaviour and develop effective strategies to support their development and manage any potential risks.

Who should use this form?:

Any team member or adult caregiver who witnesses or involved in an incident involving a child under our supervision should complete this form.

If you are a team member and have an incident or near miss, this needs to be communicated immediately to your supervisor.

Section 1: Person completing the form

Full Name completing the form

Role of the person completing the form

Contact details of the person completing the form

Section 2: Person Involved in the Incident Details

First Name

Last Name

Date of Birth

Gender

MaleFemaleNon-BinaryNot Specified

Name of Person for Notification (if different from above)

Email Address

Mobile Number

Date Person for Notification was contacted (if applicable)

Section 3: Details of Incident

Incident Reported by

Contact Details

Date and time of the Incident

Exact Location of the Incident

NDIS Reportable Incident

YesNo

Date reported to NDIS

Were there any witnesses?

YesNo

If yes, please list the witnesses’ full names as well as a contact number for each

Describe how the incident occurred and if there was any damage to property or equipment (include: led up to the event, the actual event and any equipment, work practices, tasks or processes that may have been involved - attach a separate sheet if necessary)

Concerns Raised and Additional Comments

Attach Additional Information/ Separate Documents

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Names of the person/s involved in the incident (specify if they are client, employee, student, or visitor)

Did this incident result in an injury?

Yes- Complete Section 3No- Continue to Submit

Section 4: Injury details

Nature of injury e.g., sprain, cut, burn

Details of injury sustained

Was any treatment provided?

YesNo

If yes, please provide details (e.g., first aid given by who, referred to e.g. GP)

Was any equipment involved in the injury?

YesNo

If yes, please provide details

Signature person completing the form

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