Incident Report Form - Electronic Completion
Page 1Department of Health
For more information on reporting an incident, please refer to http://www.dhs.vic.gov.au/funded-agency-channel/about-service-agreements/incident-reporting/health
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Steps 1 – 6 are to be completed by the most senior staff member present at the time of the incidentStep 1: When did the incident happen?
Date of Incident DD/MM/YYYY: / Time of Incident: / AM / PM
If you did not see the incident, when were you first told about it? DD/MM/YYYY: / Time first told: / AM / PM
Step 2: Type of incident
Choose ONE incident type only
.Please note an asterix * if the incident type denotes a compulsory Category 1 incident type
Incident types – A-B: / Select from dropdown Absconded/Breaking curfewAbsconded/Breaking curfew - attemptedAccident (without injury)Administrative ErrorAssault Physical - ActualAssault Physical - ThreatenedAssault Sexual - IndecentAssault Sexual - Rape Actual*Assault Sexual - Rape ThreatenedBehaviour - dangerousBehaviour - disruptiveBehaviour - sexualBehaviour - verbal abuseBreach of privacy confidentiality matters / For incident type Drug/Alcohol, please select a substance type from list below:
Incident Types - C-L: / Select from dropdown Community ConcernDeath - client*Death - other than client or staff*Death - staff*Drug/Alcohol - useDrug/Alcohol - possible overdose*Fire - majorFire - minorIllnessInjury - client requiring medical attentionInjury - client not requiring medical attentionInjury - staff requiring medical attentionInjury - staff not requiring medical attention / Select from dropdown AlcoholAmphetaminesBarbituratesBenzodiazepinesCannabis/marijuanaChroming/InhalentsHallucinogensHeroin/NarcoticsMultiple DrugsOtherUnknown
Incident types – M-R: / Select from dropdown Medical condition (known) deteriorationMedication error - incorrectMedication error - missedMedication error - otherMedication error - pharmacyMedication error - prn misuseMedication error - refused by clientMissing person/sMoney - missingNeglectPoor quality of care concernPossession - alcohol/ cigarettesPossession - illegal arms/dangerous goods/matchesPossession - illegal drugs/syringe/drug equipmentProperty - damageProperty - damage threatenedProperty - disruption premises (building problem)Property - prowlers at premisesProstitution*
Incident types – S-Z: / Select from dropdown Self harm - attemptedSelf harm - threatenedSelf harm - suicide attemptedSelf harm - suicide threatenedSexual harrassmentTheft /robberyVehicle accident - major injuryVehicle accident - minor /no injury
Category: / 1 / 2 / 3
Assault:
For incidents involving alleged or actual assault, select
perpetrator > victim.
All staff > 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/ 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
If more than three clients/witnesses are involved in an incident, please attach an additional sheet with their details.
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 box
if injured / Tick box if medical attention
required
1
2
3
Step 4: Where did it happen?
Address/location of incident:
Step 5: Reporting Details
Region: / Select from dropdown Barwon South WesternEastern Metropolitan50 Lonsdale Street MelbourneGippslandGrampiansHumeLoddon MalleeNorth and West MetropolitanSouthern Metropolitan / If ‘Other’, please specify:
Program: / Select from dropdown Aged Care SrvcsAlcohol and Drug ServicesCommunity HealthHome and Community CarePDRSSSupported Residential Services / Regional reference number:
Reporting Organisation:
Facility/Program Name:
Step 6: What happened?
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):
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Describe the incident and the immediate response of staff :Page 1Department of Health
Type of service provided to the client: / Date of last contact between client & service:Reporting officer’s name: / Reporting officer’stelephone:
Position: / Program:
Date of report:
Signed: / Time of report:
Step 7: What actions have been taken?
To be completed by House Supervisor/Coordinator, Line Manager, CEO, or Agency Manager
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Please describe what actions have been taken to address safety risks and what will be done to prevent reoccurrence of the incident:Page 1Department of Health
Local CASA Support offered: / Yes / Not required / AcceptedLine 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 completed electronically then signed and emailed to the appropriate address as follows:
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Southern: / / Grampians /Eastern: / / Loddon Mallee /
Hume: / / North and West /
Gippsland: / / Barwon South Western /
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:
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Follow up action required:Page 1Department of Health
Endorsement of Program ManagerSigned: / Date:
Endorsement of Director Health and Aged Care
Name: / Telephone:
Signed: / Date:
Additional Comments
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 the 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
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AOD and PDRS Services: /Supported Residential Services: /
HACC: /
Aged Care: /
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