Incident Report Form

Departmental Incident Reporting Instruction

Steps 1 6 are to be completed by the most senior staff member present at the time of the incident Please use black pen only

Step 1: When did the incident happen?

Date of Incident DD/MM/YYYY:
If you did not see the incident, when were you first told about it? DD/MM/YYYY:

Time of Incident:
Time first told:

AM AM

PM PM

Step 2: Type of incident

Choose ONE incident type only .Please note an asterix * in the incident type denotes a compulsory Category 1 incident type

Incident Type: Category: Assault: For incidents involving alleged or actual assault, select perpetrator > victim. All staff > client assaults are mandatory category 1 incidents. Volunteer carers should be recorded as staff.
Abuse in Care (Child protection clients only):
Abuse in care refers to alleged or actual physical or sexual assault where a client in care is the victim, and the perpetrator is either a carer or a member of the carers household.

Perpetrator
Client Staff Other Client

Victim
Staff Other

Is this an incident of abuse in care? Has an investigation been initiated? Have immediate safety needs been met?

Yes Yes Yes

No No

No

Date:

Please provide details (e.g. carer stood down or client removed from placement):

Compulsory Treatment Order (Disability Services clients only):

Please select if any of the clients involved are on a compulsory treatment order under the Disability Act (2006).

Yes

Step 3: Who was involved?

Please complete for each client involved in the incident, including witnesses
Sex (M/F) Tick box if Aboriginal or Torres Strait Islander Client Date of Birth
Participant /Witness

Clients/Witnesses

Family Name

First Name

Where the person lives

(P/W)

Tick box if injured

Tick box if medical attention required

1 2 3 4
If more than four clients/witnesses are involved in an incident, please attach an additional sheet with their details. Please complete for each staff member/carer involved in the incident, including staff who witnessed the incident:
Family Name First Name Staff Position Title Phone Tick box if injured Tick box if medical attention required Tick box if DINMA completed (DHS only)

Staff/Carer

1 2 3 4

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Incident Report Form 2010 Version 3.1 Page 1

Date Printed: 18/05/2011

Step 4: Where did it happen?

Address/location of incident:

Step 5: Reporting details

Refer to attached Region and Program lists

Region/YJ: Program: Reporting Organisation: Facility/Program Name:

If Other, please specify: Regional reference number:

Cost centre code:

(only for Department services)

Step 6: What happened?

Incident details should be a brief factual account of the Incident. Include who was involved; how, where and when the incident occurred; who was injured and the nature and extent of injuries (if applicable). If more space is required, please attach an additional clearly labelled sheet.

Describe the incident and the immediate response of staff:

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Date Printed: 18/05/2011

Equipment damaged?

Yes

No

Details of damage If more space is required, please attach an additional clearly labelled sheet:

Reporting officers name: Position: Signed:

Reporting Officers Telephone:

Program: Date of report: Time of report:

Step 7: What actions have been taken?

To be completed by house supervisor/coordinator, line manager, CEO, or agency manager

Please describe what actions have been taken to address safety risks and what will be done to prevent recurrence of the incident. If more space is required, please attach an additional clearly labelled sheet:

Local CASA Support offered: Line manager/CEO informed: Police contacted: Police officers name: Police investigation: Coroner contacted: WorkSafe Victoria notified: Incident report checked: Print Name: Position: Signed:

Yes Yes Yes Yes Yes Yes Yes

Not required Not required Not required Not required Not required Not required

Accepted Time: Time: Number: Date: Date: Date: Date: Date: Date: Telephone:

Telephone: Date: Forward incident report to the Department.

Confidential

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Date Printed: 18/05/2011

- For completion by Department regional staff only -

Step 8: Regional program review

To be completed by Program Manager e.g. disability accommodation manager, disability partnerships manager, child protection manager, housing manager

Name: Telephone: Incident report quality checked: Follow up action required:

Position: Date incident report received: Yes

Signed:

Date:

Step 9: Endorsement of regional executive officer or Director, YJCS

Name: Position:

Signed:

Date:
Category one incidents only

Name: (Contact person) Relevant EDs and D Legal to be informed: Child Safety Commissioner to be informed: Property and Asset Management Branch informed:
Major fire/serious property damage only

Telephone: Yes Yes Yes Not required Not required If Yes, please complete additional fields below. Date: Not required Ministerial No Date: Date:

Is this incident report required to be provided to the Ministers Office: Minister and Secretary of the Department to be informed: Does this incident report require a Ministerial brief: Inquiry recommended:

Yes

No

Yes Yes

Departmental

Endorsement of Regional Director

Signed (R/D or Director, YJCS) Additional Comments: Date:

Confidential

Incident Report Form 2010 Version 3.1 Page 4

Date Printed: 18/05/2011

Incident reporting - region, program and incident type list

December 2010

Region list
Barwon South Western Region Eastern Metropolitan Region 50 Lonsdale Street Gippsland Rural Region Grampians Rural Region Hume Rural Region Loddon Mallee Rural Region North and West Metropolitan Region Southern Metropolitan Region Youth Justice Custodial Services

Program list
Aged Care Svcs Alcohol and Drug Services Community Health CYFD Child First CYFD Family & Specialist Services CYFD Homebased Care CYFD Protective services CYFD Residential Care CYFD YJ /YS Community Services Disability Info Planning and Capacity Building Disability Individual Support Disability Residential Support Accommodation Disability Targeted Services Home and Community Care Housing Community Housing Housing Long-term assistance Housing Public Housing Housing - Support Accommodation Assistance Housing Transitional Housing Assistance PDRSS Secure Welfare Services Youth Justice Custodial Services Malmsbury* Youth Justice Custodial Services Melbourne* Youth Justice Custodial Services Parkville*
*only shown as Youth Justice Custodial Services on the online forms; facility detail added when entering on TRIM

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Date Printed: 18/05/2011

Incident type list

In relation to assaults, the perpetrator status is nominated first, the victim second perpetrator > victim Absconded/breaking curfew/escape - attempted Absconded/breaking curfew/escape - successful Accident (without injury) Administrative Error Assault Physical - Actual client > client Assault Physical - Actual client > other Assault Physical - Actual client > staff Assault Physical - Actual other > client Assault Physical - Actual staff > client* Assault physical threatened client > client Assault physical threatened client > other Assault physical threatened client > staff Assault physical threatened other > client Assault physical threatened staff > client* Assault Sexual - Indecent client > client Assault Sexual - Indecent client > other Assault Sexual - Indecent client > staff Assault Sexual - Indecent other > client Assault Sexual - Indecent staff > client* Assault Sexual - rape actual client > client* Assault Sexual - rape actual client > other* Assault Sexual - rape actual client > staff* Assault Sexual - rape actual other > client* Assault Sexual - rape actual staff > client* Assault Sexual - rape threatened client > client Assault Sexual - rape threatened client > other Assault Sexual - rape threatened client > staff Assault Sexual - rape threatened other > client Assault Sexual - rape threatened staff > client* Behaviour - verbal abuse Behaviour- dangerous Behaviour- disruptive Behaviour- sexual Breach of privacy confidentiality matters Community concern Death- client* Death- other* Death- staff* Drug/Alcohol - Possible Overdose Alcohol* Drug/Alcohol - Possible Overdose Amphetamines* Drug/Alcohol - Possible Overdose Barbiturates* Drug/Alcohol - Possible Overdose Benzodiazepines* Drug/Alcohol - Possible Overdose - Cannabis/Marijuana* Drug/Alcohol - Possible Overdose - Chroming/Inhalants* Drug/Alcohol - Possible Overdose Hallucinogens* Drug/Alcohol - Possible Overdose - Heroin/Narcotics* Drug/Alcohol - Possible Overdose - Multiple Drugs* Drug/Alcohol - Possible Overdose Other* Drug/Alcohol - Possible Overdose Unknown* Drug/Alcohol - Use - Unknown Drug/Alcohol - Use - Alcohol Drug/Alcohol - Use - Amphetamines Drug/Alcohol - Use - Barbiturates Drug/Alcohol - Use - Benzodiazepines Drug/Alcohol - Use - Cannabis/Marijuana Drug/Alcohol - Use - Chroming/Inhalants Drug/Alcohol - Use - Hallucinogens Drug/Alcohol - Use - Heroin/Narcotics Drug/Alcohol - Use - Multiple drugs Drug/Alcohol - Use - Other Escape Fire- major Fire- minor Illness Injury- to client not requiring medical attention Injury- to client requiring medical attention Injury- to staff not requiring medical attention Injury- to staff requiring medical attention Medical condition (known)- deterioration Medication error - incorrect Medication error - missed Medication error - PRN misuse Medication error - refused by client Medication error- other Medication error- pharmacy Missing person/s Money - missing Neglect Poor quality of care concern Possession - of illegal arms, explosives, dangerous goods, matches, lighter Possession - of illegal drugs/syringe/drug use equipment Possession- of alcohol or cigarettes Property- damage Property- disruption at premises (building problems) Property-damage threatened Self harm - suicide threatened Prostitution Self harm - attempted Self harm - suicide attempted Self-harm - threatened Theft/Robbery Property-Prowlers on/at premises Sexual harassment Vehicle accident (major injury)

Confidential

Incident Report Form 2010 Version 3.1 Page 6

Date Printed: 18/05/2011