5 Castlemaine Street
Kirwan  QLD  4817
Ph.  07 4779 6500

INCIDENT REPORT FORM 

Date of Report ………………….					         Registered Report No…………..

PROCEDURE FOR COMPLETING REPORT: 
•	In the first instance, all incidents must be reported immediately to a member of the Management Team; 
(If outside of office hours, phone the ‘On Call’ emergency number). 
•	A member of the Management Team will assist. 
•	This form is to be completed within 48 hours or on the next business day after a member of the management team has been informed.  
•	This form is to capture all incidents such as:  physical injuries, accidents, near misses, safety hazards, abusive interactions, property damage etc. that occur during work times and when you travel on your regular journey to and from work. 
•	Community Connection is obligated to report serious incidents to the relevant statutory bodies. 

FAMILY/INDIVIDUAL DETAILS	
FAMILY	LIFESTYLE ASSISTANT	
Christian Name: 		Worker ‘s Name: 		
Surname:				
Address:
		Address: 		
Phone:  		Phone:		
Date of Birth:		Date of Birth:		
Date Reported to Management Team: 		Time Reported: 		
Name of Management Team Member Reported to: 		
ACCIDENT/INCIDENT DETAILS	

Name of Person/s Injured/Involved:  ………………………………………

………………………………………………………………………………….

…………………………………………………………………………………

Signature of 
Employee:  ……………………………………………………………
Date: …………………………
	
Time
Injured/Incident:  …...……am/pm

Date 
Injured/Incident:   .…./..…/20…..

Location where Injury/Incident occurred:   …………………………………………………………………………...

……………………………………………………………………………………………………………………………

Description of Event/ Type of Incident/Potential risk:  …………………………………………………………………

…………………………………………………………………………………………………………………………….

 ……………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………
Please report facts only – no interpretation of events please	

Direct Cause of Injury:  (e.g. slippery floor) /Behavioural triggers…………………………………………………

……………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………..

Bodily Location of Injury: (e.g. right lower arm- or please indicate location on attached body map)  
Please complete a body map for each person’s injuries

Type of Injury/disease/harm/damage: (e.g. open wound, sprain) …………………………………………………………………………………………..…………………………………	

	Impact of Injury							Description of actions:
	(Please tick one) 						(Please tick one)
Insignificant	
	
Report Only	

Minor	
	
First Aid Treatment	

Moderate	
	
Medical Treatment	

Major	
	
Hospitalization	

Catastrophic	
	
Work Cover Claim 	

	

Witness Details:                                                           Phone Contact Details: 

1.	……………………………………………………………………………………………………………………

2.	…………………………………………………………………………………………………………………...

3.	……………………………………………………………………………………………………………………

Action / Remedy /Preventative Measure Taken at the time of the incident:  ……………………………………
……………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………..	

TO BE COMPLETED BY SUPERVISOR/ RETURN TO WORK PLACE HEALTH & SAFETY REPRESENTATIVE	
Formal Investigation Required:  	Yes   /   No	
Safety Alert or Other Notice Required:  	Yes   /   No	
Recommended preventative long-term action to be taken:	Yes   /   No	
Work Cover Compensation Paper Work Required	Yes   /   No	
If Work Cover Claim lodged, has a Medical Certificate been issued?	Yes   /   No	
Does Workplace Health & Safety Queensland need to be notified?	Yes   /   No	
Is this a critical incident – does Disability Services need to be notified?	Yes   /   No	
Type of Incident	Action Taken	
		
Type of Incident (M=no or minimal action; S =Serious - follow-up required; C=Critical - urgent attention required	

Report Completed and Signed Out
Signature:  	
Date:	

OFFICE USE ONLY		

Information Entered into Incident Registered by:  	
Date: 	

INCIDENT REPORT FORM (Attachment)

Injury Report Body Map 

Individual’s Name ___________________________                         Date: ___________

Mark Area(s) Affected

Name of Support Worker: _________________________

Signature of Support Worker: ______________________   Date:   _________