Form: Incident Log

Incident Date [?] *
Incident Time
Location [?] *
Witnesses [?] *
Emergency Assistance [?] *
Police Involvement [?]
Police Event Number [?]
Person Search - Restricted Practice [?]
Person Room Search - Restricted Practice [?]

Antecedent [?] *
Behaviour *
De-escalation *
Consequence *
Possible Function *

If a Body Chart is required to be completed please download one from the following links.
To complete a body chart open the link below, and save or print the PDF.

Two Page Option: https://app.ctars.com.au/Files/PDF/CTARSBodyChart(2_Pages).pdf
One Page Option: https://app.ctars.com.au/Files/PDF/CTARSBodyChart(1_Page).pdf

Using a PDF editor, or by printing and scanning to a file; indicate the relevant area(s) of concern on the body chart.
Include the Incident Log reference number in the file name of the Body Chart and attach in documents.

Agitation/Hyperarousal [?]
Attempted/Minor Property Damage [?]
Disclosure or Serious Client Complaint [?]
Disruption to Routine [?]
Injury – Minor client injury - First Aid Only [?]
Non-compliance/Task Refusal [?]
Physical Threats of Self-Harm [?]
Verbal Abuse/Swearing [?]
Verbal Threats of Self-Harm [?]
Verbal Threats toward Others (persists for less than 10 minutes or one instance) [?]

Absconding (Habitual) [?]
Incident involving another person [?]
Injury – Medium - Requiring Medical Attention [?]
Medication Error
Physical Assault or Threats (Managed in-house) [?]
Property Damage (Managed in-house) [?]
Risk Taking Behaviours [?]
Self-injurious Behaviour (Managed in-house) [?]
Sexual Behaviour (touching, soliciting, gestures) [?]
Verbal Abuse (Persists for more than 10 minutes) [?]

Absconding requiring Missing Persons Report [?]
Assault Requiring Medical Support [?]
Behaviour or Challenges Attracting Community Concern [?]
Behaviour or Challenges Attracting Media Attention [?]
Extreme Property Damage [?]
Extreme Risk Taking Behaviour [?]
Illicit Substance or Alcohol Possession/Use [?]
Injury/Injuries resulting in Immediate Medical Attention Required [?]
Sexual Activity
Self-Injurious Behaviour [?]

Abuse or Neglect of the Client
Criminal Behaviour Resulting in Clients Held in Custody [?]
Death or Fatal Injury of a Carer/Community Member [?]
Death or Fatal Injury of a Client [?]
Serious Injury of the Client
Unlawful Sexual or Physical Contact with, or Assault of the Client
Sexual Misconduct Committed Against, or in the Presence of the Client, Including Grooming of the Client for Sexual Activity
Unauthorised Use of Restricted Practice in Relation to the Client
Reportable Conduct by a Carer/Staff Member [?]

Rating of Incident *

Risk of Significant Harm reported? [?]*
Date
Time
Helpline Case Worker Name
Reference Number

Physical Intervention [?]
Type of Physical Intervention [?]
How long did the physical intervention last? [?]
Client Injury [?]
Staff Injury [?]

Has the client been offered diffusion or debrief?
Has the client disclosed or made accusation of assault or abuse?
Has the client (or Guardian) been made aware of their rights to involve the police and potentially press charges?
Has the staff been offered diffusion or debrief?
Has the staff member been made aware of their rights of involve the police and potentially press charges?

Follow up required?
Was On Call/Management Contacted? [?]

PRN Approved [?]
PRN Provided [?]
PRN Notes [?]

Nature of Call
Actions
Result
Follow Up

Staff Member Name [?]*

Signature
Name

Many of the above Critical Level Categorisations are determined to be Reportable Incidents by the NDIS. If this Incident is identified as Critical, consider the following for Mandatory Reporting to the Commissioner. 

a) abuse or neglect of a person with disability

b) death of a person with disability 

c) serious injury of a person with disability

d) unlawful sexual or physical contact with, or assault of, a person with disability

e) sexual misconduct committed against or in the presence of, a person with disability, including grooming of the person for sexual activity

f) use of a restricted practice in relation to a person with disability, other than where the use is in accordance with an authorisation of a State or Territory for that person, or not in accordance with a Behavioural Support Plan for that person. 

 

In the case of a Reportable Incident (NDIS Quality and Safeguards Commission) 

Reportable Incident Immediate Notification Form :
 https://www.ndiscommission.gov.au/document/661 

Reportable Incident - 5 Day Notification Form:
 https://www.ndiscommission.gov.au/document/656 

 

It is recommended you access the form directly from the NDIS Commission website to complete each time a reportable incident occurs. 
The requirement to report to the NDIS Commission does not replace existing obligations on providers to report to other relevant authorities, including child protection agencies or police.

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