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Report Incident below
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1
Incident Summary
2
Incident details
3
Corrective Actions
4
Final Resolution
Name
First
Last
Name of participant/client involved in the incident
Name
First
Last
Name of the staff person reporting the incident
Date
*
DD slash MM slash YYYY
Date of the incident
Address
*
Street Address
Suburb
Location of incident
What happened?
*
In one line describe what happened. e.g. ‘client fell whilst walking’ or ‘client burnt hand when making cup of tea’
Incident details
What task was being performed at the time of the incident? (e.g “mobility training”, “non- therapy snack preparation”
What factors contributed to the incident?
Environment
Equipment/materials
Work systems or process
People
Others
What factors contributed to the incident?
Describe the environment factors
Trip hazards in environment (& / or too crowded)
Inadequate lighting
Inadequate housing
Other
Describe Equipment or materials risks
Required equipment not available
Equipment failure / Inadequate maintenance
Inadequate training provided
Other
Describe the work systems or process flaw
Risk not identified
No / inadequate risk assessment conducted (eg on client)
Inadequate training / understanding of the risk
No / inadequate controls implemented eg work procedures
No / inadequate work procedure
Other
Select which people risk might have caused this
Lack of communication
Procedure not followed
Fatigue
Distraction / personal issues / stress
Change of routine
Lack of skills
Other
Describe other risks
Describe these risks
Contributing factor (from above list)
What are we going to do to fix the problem?
Who will take action
First
Last
When will this action take place?
DD slash MM slash YYYY
When will the action be completed
MM slash DD slash YYYY
Issue fixed?
Yes
No
Describe Lesson-Learned
Consent
I agree to the corrective actions and resolution of this incident
Enter incident resolution and risk management manager comments
Phone
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