Part 1: Reporter Details

Name of the person reporting this incident*

Contact number: *

Incident Report Number: *

Position Title: *

City:

Part 2: Incident Details

Date of Incident:

Time of Incident:

Address:

Date first told you about the incident (if applicable):

Time first told you about the incident (if applicable):

Part 3: Who was involved?

Participants: details

Full Name:

Date Of Birth:

Address:

Involved/Witness:

Injured ?

YesNo

Medical Attention required ?

Staff/Carer or Others: details

Full Name:

Address:

Staff/Other:

Involved/Witness

Injured ?

Medical Attention required?

Part 4: Incident Background

(eg. What was client doing before incident) ?

Part 5: What happened?

Incident Description:

Immediate action taken by Staff:

Was any property or equipment damaged?

Police Contacted?

Details of Damage (if Applicable):

Incident reported to the Line Manager?

Manager’s name:

Date:

Part 6: Manager’s report

Manager's Name :

Contact:

Position:

What action have been taken and what follow up actions will be taken in response to the incident?

Line Manager/ General manager Informed?

Informed Date:

Informed Time:

Report Quality checked?

Does the severity of this incident require notification to Work Safe Victoria?

Type Your Signature Here

Incident Report Form

Part 1: Reporter Details

Part 2: Incident Details

Part 3: Who was involved?

Part 4: Incident Background

Part 5: What happened?

Part 6: Manager’s report