Incident Report Location & Time Details Of Incident / Accident Date of Incident Time of Incident ampm Area : Exact Location of Incident : Street : Suburb : State : Person Reporting : Contact Number : Status : ParticipantWorkerVisitorPublic Location & Time Details Of Incident / Accident Give a full description of the incident : How was the injury or damage sustained? (e.g. slipped on wet ground) NATURE OF INCIDENT Injury – First Aid TreatmentInjury–Medical TreatmentInjury –HospitalisationSexual or Physical assaultDeathAbuse or neglectRestricted WorkWaste incidentMedication Incident INJURY INFORMATION OF CLIENT/PARTICIPANT (If more than one add more sheets) Name : Sex : MaleFemaleOther Birth Date : Phone : NDIS Number : Status : ParticipantWorkerVisitorPublic Body Part : Eye or FacialHead or BrainBackShouldersHipAbdomenArmNeckLegHands & FingersFeet & ToesOther Nature Of Injury : LacerationAbrasionCrush InjuryFractureElectric ShockDehydrationBruisingStrains/ SprainsBurnsDislocationAmputationOther Is First Aid Applied By: Full name of first Aider (if applicable) : Description of first aid treatment : PROPERTY DAMAGE (Including environmental impacts) Description of Damage WITNESSES (Attach copies of witness statements) Name : Contact Phone : Email :
