1. Provider Details:
Report Completed by
Outlet Name
Registration Group
2. Primary Contact Person
Who is the provider’s primary contact for this incident or allegation?
Title
First Name
Last Name
Position at provider
Phone Number
Email Address
Preferred method of contact
3. Incident Category:
The categories of incidents are defined in 73Z of the National Disability Insurance Scheme Act 2013 (Cth) and section 16 of the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018. You may wish to include a secondary category if the incident/allegation falls into multiple categories.
Primary Category
Death of a person with disability Serious injury of a person with disability Abuse of a person with disability Neglect of a person with disability Unlawful sexual acts/offences Unlawful physical contact/offences Sexual misconduct against a person with disability Unauthorised use of a Restrictive Practice
Secondary Category
Death of a person with disability Serious injury of a person with disability Abuse of a person with disability Neglect of a person with disability Unlawful sexual acts/offences Unlawful physical contact/offences Sexual misconduct against a person with disability Unauthorised use of a Restrictive Practice
4. Incident Details:
If you have completed an internal incident report please provide it to the NDIS Commission with this report.
Incident Location
Time of incident/allegation
Date of incident/allegation
If date unknown, reason why
Time the NDIS provider became aware of incident
Date & time NDIS provider became aware of incident
Describe the incident/allegation
What were the circumstances leading up to the incident/allegation?
5. Impacted Person:
Title
First and last name
NDIS participant number
Gender
Male Female Indeterminate Intersex Unspecified
Date of birth
Primary disability
Autism Intellectual Disability Cerebral Palsy Psychological Disability Other Neurological Other Physical Acquired Brain Injury Visual Impairment Hearing Impairment Other Sensory/Speech Multiple Sclerosis Stroke Spinal Cord Injury Other
Other disability
Autism Intellectual Disability Cerebral Palsy Psychological Disability Other Neurological Other Physical Acquired Brain Injury Visual Impairment Hearing Impairment Other Sensory/Speech Multiple Sclerosis Stroke Spinal Cord Injury Other
Does the person have any behaviours of concern?
Food-related Eating non-food items Property damage Physical aggression Verbal aggression Harm to self Unintentional self-risk Leaving premises w/out support Refusal to do things Repetitive or unusual habits Offending behaviour Sexually inappropriate behaviour Other
How does the person communicate?
Verbal Communication Adjusted Verbal Language Electronic Communication Picture Communication Sign Language Other Signing Use of Gestures Interpreter Other
Phone number
Email address
6. Subject(s) of Allegation:
A subject of allegation is a person who has been accused of a reportable incident.
A subject of allegation may be a worker within your organisation or another person, for example a resident living in the same house. There may be more than one subject of allegation. If there is not space on this form, please include additional information in an attachment.
6.1 Subject of allegation - worker:
Only complete this section if there is a worker who is a subject of allegation.
Title
First Name
Position at time of allegation
Gender
Male Female Indeterminate Intersex Unspecified
Date of birth
Phone number
Email
6.2 Subject of allegation - person with disability:
Title
First Name
NDIS participant number
Gender
Male Female Indeterminate Intersex Unspecified
Date of birth
Primary disability
Autism Intellectual Disability Cerebral Palsy Psychological Disability Other Neurological Other Physical Acquired Brain Injury Visual Impairment Hearing Impairment Other Sensory/Speech Multiple Sclerosis Stroke Spinal Cord Injury Other
Other disability
Autism Intellectual Disability Cerebral Palsy Psychological Disability Other Neurological Other Physical Acquired Brain Injury Visual Impairment Hearing Impairment Other Sensory/Speech Multiple Sclerosis Stroke Spinal Cord Injury Other
Does the person have any behaviours of concern?
Food-related Eating non-food items Property damage Physical aggression Verbal aggression Harm to self Unintentional self-risk Leaving premises w/out support Refusal to do things Repetitive or unusual habits Offending behaviour Sexually inappropriate behaviour Other
How does the person communicate?
Verbal Communication Adjusted Verbal Language Electronic Communication Picture Communication Sign Language Other Signing Use of Gestures Interpreter Other
Phone number
Email
6.1 Subject of allegation - other:
Title
First name
Relationship to impacted person
Gender
Male Female Indeterminate Intersex Unspecified
Date of birth
Phone number
Email
7. Immediate Action Taken:
Officer's name
Police station
Police event number
If the police have not been informed, why not?
7.1 Impacted Person:
If the incident category is death of a person with disability, this section does not need to be completed.
Describe any immediate support that has been offered/provided to the person with disability impacted by the incident (for example, medical treatment, counselling, access to advocacy, removed source of harm)
7.3 Subject of allegation - person with disability:
This only needs to be completed if there is a person with disability who is a subject of allegation.
Describe any immediate action that has been taken or commenced in respect to the person with disability who is the subject of the allegation (for example, review of staffing, review of behaviour support needs, medical review, assistance to access support person or advocate)
8. Risk Assessment:
If you have completed a risk assessment please provide it to the NDIS Commission with this report.
If yes, date risk assessment was complete
Details of risk assessment
If no risk assessment has been undertaken, what is the reason for not undertaking a risk assessement?
If you have a risk assessment in progress, when was it started?
When do you expect to be finished?
9. Attachments:
Please upload all supporting documents you need to submit to the NDIS Commission here.
File Attachments
10. Declaration:
Full Name
Position at organisation
Date
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