Incident Report Form
For more information on reporting an incident, please refer to http://www.dhs.vic.gov.au/funded-agencychannel/about-service-agreements/incident-reporting/health
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:
(Specify ONE incident type only)
For incident type Drug/Alcohol, please
specify the substance type:
Category:
1
Assault
Perpetrator:
For incidents involving alleged or actual assault,
specify the perpetrator and victim. All staff on client
assaults are mandatory category 1 incidents.
Client
2
3
Victim:
Staff
Other
Client
Staff
Other
Step 3: Who was involved?
Clients/Witnesses
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
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/Carer
Staff Position Title
Initials only. Name not to be recorded
1
2
3
Page 1
Department of Health
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?
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’s
telephone:
Position:
Signed:
Page 2
Date and time of report:
Department of Health
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
Line manager/CEO informed:
Yes
Not required
Time:
Date:
Police contacted:
Yes
Not required
Time:
Date:
Number:
Telephone:
Police officer’s name:
Accepted
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:
Eastern:
Hume:
Gippsland:
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SouthernDH.Incidents@health.vic.gov.au
EasternDH.Incidents@health.vic.gov.au
HumeDH.Incidents@health.vic.gov.au
GippslandDH.Incidents@health.vic.gov.au
Grampians
Loddon Mallee
North and West
Barwon South Western
GrampiansDH.Incidents@health.vic.gov.au
LoddonDH.Incidents@health.vic.gov.au
NorthWestDH.Incidents@health.vic.gov.au
BarwonDH.Incidents@health.vic.gov.au
Department of Health
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
Assault physical threatened staff > client*
Fire- major
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
Behaviour- disruptive
Possession - of illegal arms, explosives, dangerous goods,
matches, lighter
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.
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Department of Health
To be completed by DH Program Manager and endorsed by Director, Health and Aged Care
Step 10: Regional office review
Name:
Client initials only (name not to be recorded):
Telephone:
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)
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Department of Health
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:
Legal Services Branch informed:
Yes
Capital Projects and Service
Planning Branch informed:
Yes (Major fire/serious property damage only)
Not Required
Not Required
Additional requirements for category one incident with the 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:
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MHDR.Incidents@health.vic.gov.au
SRS.Incidents@health.vic.gov.au
HACC.Incidents@health.vic.gov.au
Aged.Incidents@health.vic.gov.au
Department of Health