Incident Report | Chosen Care

1. LOCATION & TIME DETAILS OF INCIDENT / ACCIDENT

Date of Incident :

Time of Incident :

Area :

The Exact Location of Incident :

Street :

Suburb :

State :

Person Reporting :

ParticipantWorkerVisitorPublic

Contact Number :

Email :

2. DESCRIPTION OF INCIDENT

Give a full description of the incident :

How was the injury or damage sustained?

Consultation with the participant :

3. NATURE OF INCIDENT

Select Nature Of Incident

Injury- First Aid treatmentRestricted WorkWaste IncidentMedication Incident

Injury-Medical TreatmentInjury- HospitalisationSexual or Physical AssaultDeathAbuse or Neglect

The following incidents (including allegations) arising must be reported to the NDIS Commission :

The death of an NDIS participantSerious injury of an NDIS participantAbuse or neglect of an NDIS participantUnlawful sexual or physical contact with, or assault of, an NDIS participantSexual misconduct committed against, or in the presence of, an NDIS participant, including grooming of the NDIS participant for sexual activityThe unauthorised use of restrictive practice by an NDIS participant

4. INJURY INFORMATION (Person involved in the incident/accident, if more than one fill out a separate form)

Name :

Job Title :

Date of Birth :

Sex :

MaleFemale

Status :

ParticipantWorkerVisitorPublic

Phone Number :

Email :

NDIS Number :

Body Part :

Eye or FacialHead or BrainBackShouldersHipAbdomenArmNeckLegHands & FingersFeet & ToesOther

Nature of the Incident :

LacerationAbrasionCrush InjuryFractureElectric ShockDehydrationBruisingStrains/ SprainsBurnsDislocationAmputationOther

Caused By :

Full Name of the First Aider (if applicable) :

Description of Action Taken / First Aid Treatment :

5. PROPERTY DAMAGE (Including Environmental Impacts)

Description of Damage

6. WITNESSES (Attach Copies of Witness Statements)

Upload Relevant Documents (Eg: Witness Statements)

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