Page 1Department of Health

For more information on reporting an incident, please refer to

Steps 1 -6 are to be completed by the most senior staff member present at the time of the incident

Step 1: When did the incident happen?

Date of Incident: / Time of Incident: / am/pm
If you did not see the incident, when were you first told about it?: / Time first told: / am/pm

Step 2: Type of incident (See page 4, below, for a list of incident types)

Incident type:
(SpecifyONE incident type only)
For incident type Drug/Alcohol, please specify the substance type:
Category: / 1 / 2 / 3
Assault
For incidents involving alleged or actual assault, specify the perpetrator and victim.All staff on client assaults are mandatory category 1 incidents. / Perpetrator: / Victim:
Client / Staff / Other / Client / Staff / Other

Step 3: Who was involved?

Please complete for each client or external witness involved, including clients who witnessed the incident. If more than three clients/witnesses are involved in an incident, please attach an additional sheet with their details.
/ Initials only. Name not to be recorded / Sex (M/F) / Tick box if
Aboriginal or
Torres Strait
Islander / Client Age / Where the person lives
(Suburb only) / Participant
/Witness
(P/W) / Tick box if injured / Tick box if medical attention required
1
2
3
Please complete for each staff member involved in the incident, including staff who witnessed the incident:
Staff Position Title / Initials only. Name not to be recorded / Participant
/Witness
(P/W) / Tick boxif injured / Tick box if medical attentionrequired
1
2
3

Step 4: Where did it happen?

Address/location of incident:

Step 5: Reporting Details

Region: / If ‘Other’, please specify:
Program: / Regional reference number:
Reporting Organisation:
Facility/Program Name:

Step 6: What happened?

Page 1Department of Health

Describe the incident and the immediate response of staff :
Incident details should be a brief factual account of the incident. Include who was involved; how, where and when the incident occurred; who is injured and the nature and extent of injuries (if applicable).
Type of service provided to the client: / Date of last contact between client & service:
Reporting officer’s name: / Reporting officer’stelephone:
Position:
Signed: / Dateand time of report:
To be completed by house supervisor/coordinator, line manager, CEO, or agency manager

Step 7: What actions have been taken?

Please describe what actions have been taken to address safety risks and what will be done to prevent reoccurrence of the incident:
Local CASA Support offered: / Yes / Not required / Accepted
Line manager/CEO informed: / Yes / Not required / Time: / Date:
Police contacted: / Yes / Not required / Time: / Date:
Police officer’s name: / Number: / Telephone:
Police investigation: / Yes / Not required / Date:
Coroner contacted: / Yes / Not required / Date:
WorkSafe Victoria notified: / Yes / Not required / Date:
Incident report checked: / Yes / Date:

Step 8: Consent and information sharing

All clients are required to complete consent and information statements at intake with the service provider. Please ensure you have consent for this person on file. Staff and witnesses will also need to consent to information being collected for this purpose.
Consent by client/s provided / Yes / No
Consent by staff and witness/s provided / Yes / No
Step 9: Authorisation(Authorisation must be provided by the funded agency manager or CEO)
Print Name:
Position: / Telephone:
Signed: / Date:

All incident reports must be signed and emailed to the appropriate address as follows:

Southern: / / Grampians /
Eastern: / / Loddon Mallee /
Hume: / / North and West /
Gippsland: / / Barwon South Western /
Incident type list
In relation to assaults, the perpetrator status is nominated first, the victim second – perpetrator > victim
Absconded/breaking curfew/escape - attempted / Drug/Alcohol - Use - Unknown
Absconded/breaking curfew/escape - successful / Drug/Alcohol - Use - Alcohol
Accident (without injury) / Drug/Alcohol - Use - Amphetamines
Administrative Error / Drug/Alcohol - Use - Barbiturates
Assault Physical - Actual client > client / Drug/Alcohol - Use - Benzodiazepines
Assault Physical - Actual client > other / Drug/Alcohol - Use - Cannabis/Marijuana
Assault Physical - Actual client > staff / Drug/Alcohol - Use - Chroming/Inhalants
Assault Physical - Actual other > client / Drug/Alcohol - Use - Hallucinogens
Assault Physical - Actual staff > client* / Drug/Alcohol - Use - Heroin/Narcotics
Assault physical threatened client > client / Drug/Alcohol - Use - Multiple drugs
Assault physical threatened client > other / Drug/Alcohol - Use - Other
Assault physical threatened client > staff / Escape
Assault physical threatened other > client / Fire- major
Assault physical threatened staff > client* / Fire- minor
Assault Sexual - Indecent client > client / Illness
Assault Sexual - Indecent client > other / Injury- to client not requiring medical attention
Assault Sexual - Indecent client > staff / Injury- to client requiring medical attention
Assault Sexual - Indecent other > client / Injury- to staff not requiring medical attention
Assault Sexual - Indecent staff > client* / Injury- to staff requiring medical attention
Assault Sexual - rape actual client > client* / Medical condition (known)- deterioration
Assault Sexual - rape actual client > other* / Medication error - incorrect
Assault Sexual - rape actual client > staff* / Medication error - missed
Assault Sexual - rape actual other > client* / Medication error - PRN misuse
Assault Sexual - rape actual staff > client* / Medication error - refused by client
Assault Sexual - rape threatened client > client / Medication error- other
Assault Sexual - rape threatened client > other / Medication error- pharmacy
Assault Sexual - rape threatened client > staff / Missing person/s
Assault Sexual - rape threatened other > client / Money - missing
Assault Sexual - rape threatened staff > client* / Neglect
Behaviour - verbal abuse / Poor quality of care concern
Behaviour- dangerous / Possession - of illegal arms, explosives, dangerous goods, matches, lighter
Behaviour- disruptive / Possession - of illegal drugs/syringe/drug use equipment
Behaviour- sexual / Possession- of alcohol or cigarettes
Breach of privacy confidentiality matters / Property- damage
Community concern / Property- disruption at premises (building problems)
Death- client* / Property-damage threatened
Death- other* / Self harm - suicide threatened
Death- staff* / Prostitution
Drug/Alcohol - Possible Overdose – Alcohol* / Self harm - attempted
Drug/Alcohol - Possible Overdose – Amphetamines* / Self harm - suicide attempted
Drug/Alcohol - Possible Overdose – Barbiturates* / Self-harm - threatened
Drug/Alcohol - Possible Overdose – Benzodiazepines* / Theft/Robbery
Drug/Alcohol - Possible Overdose - Cannabis/Marijuana* / Property-Prowlers on/at premises
Drug/Alcohol - Possible Overdose - Chroming/Inhalants* / Sexual harassment
Drug/Alcohol - Possible Overdose – Hallucinogens* / Vehicle accident (major injury)
Drug/Alcohol - Possible Overdose - Heroin/Narcotics*
Drug/Alcohol - Possible Overdose - Multiple Drugs*
Drug/Alcohol - Possible Overdose – Other*
Drug/Alcohol - Possible Overdose – Unknown*

* Denotes a mandatory category 1 incident type.

To be completed by DH Program Manager and endorsed by Director, Health and Aged Care

Step 10: Regional office review

Name: / Telephone:
Client initials only (name not to be recorded): Yes
Date and time incident report received:
Incident report quality checked:Yes / Date:
Director Health and Aged Care informed:Yes / Date:
Debriefing approval requested:Yes / Date:
Entered in information system: Yes / Date:
Follow up action required:

Endorsement of Program Manager

Signed: / Date:

Endorsement of Director Health and Aged Care

Name: / Telephone:
Signed: / Date:
Additional Comments(for category 1 incidents, please see below)

Category one incidents only

For category one incidents without the potential to involve the Minister or produce a high level of public or legal scrutiny
Program Director informed: / Yes
Executive Director informed: / Yes
Executive Director MHDR informed: / Yes
Chief Psychiatrist informed: / Yes(Mental health service clients only) Date: / Not Required
Legal Services Branch informed: / Yes
Capital Projects and Service Planning Branch informed: / Yes (Major fire/serious property damage only) / Not Required
Additional requirements for category one incident withthe potential to involve the Minister of produce a high level of public or legal scrutiny.
Secretary to Department informed: / Yes
Ministerial brief required as soon as possible and within 48 hours.
Debriefing approved:

Completed and reviewed incident reports should be emailed to the most appropriate program area’s mailbox as follows:

AOD and PDRS Services: /
Supported Residential Services: /
HACC: /
Aged Care: /

Page 1Department of Health