Client Accident Incident Report

Support Worker to complete Sections 1 and 2 and forward without delay to the Case Manager in the event of any accident, incidsent or near miss involving a client

Section 1 - Client Details

Client's Given Name *

Client's Surname *

Date of Birth +

Client's Address *

Date occurred * +

Time Occurred: *

Section 2 - Classification

Please chose which best describes the event *

Accident

Incident

Near miss

Is the incident a 'Reportable' NDIS Incident? *

Yes - (Tick yes if death, serious injury, abuse or neglect of a person with a disability - or regarding use of restrictive practices) This must be referred to the Senior Team Leader Case Management and Client Services

Is the incident a 'Reportable' SIRS (serious Incident Response Scheme) Incident? *

Yes - (Tick yes if death, serious injury, financial or physical abuse, missing or neglect. This must be referred to the CCT Management Team immediately.

Describe what happened *

Location of accident/incident *

Describe any injuries (be specific) *

What do you think caused the event *

What immediate action did you take in response to the accident/incident/near miss? *

Employee reporting incident MUST complete the following questions

Did you report the event to the Case Manager *

Yes

Did the client require medical attention? *

Yes

Was an Ambulance required? *

Yes

Was a Doctor seen? *

Yes

Doctor's Name:

Date examined +

Were there any witness/es? (If yes, please provide name & addresses) *

Employee Signature *

clear

Employee Name: *

Employee Position *

Date * +

P:\FORMS AND POLICIES FOR COMMON CARE STANDARDS\Forms\WHS forms\Client Accident Incident Report revised 10032020 mh.docx