Incident Report Form

Incident Details

Name of Client

Reporting Staff

Time Started

Time ended

Date

Location

QP Number and Police Officer Name/s(This information is mandatory if police are in attendance)

Type of incident

Please select the most appropriate incident from the list of incidents below

Are you reporting a verbal aggression?

YesNo

Verbal Aggression

Yelling at staff or othersSwearing at staff or othersThreats of harm towards staff or othersYelling, swearing and threats of harm towards staff or othersOther

Are you reporting a property damage?

YesNo

Property Damage

No evidence of damage and no item requiring repair/replacementRepair/Replacement for holes in wallRepair/Replacement to other propertyOther-Broke the handle of the tap in clients toilet

Are you reporting a physical aggression

YesNo

Physical Aggression

Physical contact made but did not result in injuryResulted in bruising, scratching and redness, but did not require medical attentionResulted in bruising, scratching and redness, and required medical attentionResulted in serious physical injury requiring immediate medical treatmentOther

Are you reporting a setting event?

YesNo

Setting Events

Poor sleeping pattern/night terror - Discomfort, pain, or illnessMedication change/missed or late dose - Seizure activityHigh temperature/overheatingLack of structure/routine/consistencyBeing occupied/not engaged in a preferred activityMinimal social interactionHallucinations/paranoiaOther- Frosty secretions from the mouth and nostrils

Are you reporting Triggers?

YesNo

Are you reporting a Cue of distress?

YesNo

Reactive Strategies (Action Taken)

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Details leading up to the incident

Details of the Incident

Summary of actions taken

First Aid Given: (Please provide details)

Injury Diagram (Complete if Applicable)

Clear drawing

Indicate on the diagram below where the client has been injured

Name of the person completing this form *

Position

Date of submission *

Signature *

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Actions taken by Clinical Lead / Manager

Name of the Clinical Lead / Manager *

Date *