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Menu
HOME
ABOUT
OUR SERVICES
Participation in community
Community Nursing Care
Accommodation(Supported Independent Living)
Group center activities
Assist – Personal Activities
Mental Health Care
Assist -travel / transport
Daily tasks/ Shared living
Innovative community participation
Development life skills
Household tasks
NDIS Short-Term Accommodation
NDIS Household Tasks
Disability Support Worker
NDIS Service Provider
BOOK NOW
CAREERS
CONTACT
STAFF LOGIN
REFER A CLIENT
FEEDBACK & COMPLAINTS
INCIDENT REPORT FORM
Incident Report Form
Name of Person Reporting Incident:
(Required)
First Name
Last Name
Your Phone Number:
(Required)
Date of Incident
(Required)
MM slash DD slash YYYY
Name of the Participant involved in incident:
First Name
Last Name
Staff Member's email address:
(Required)
Time of Incident:
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Location of Incident:
(Required)
Address
Were Lifepath Care Services policies and procedures complied with at the time?
Yes
No
Were the participant's plans fully complied with?
Yes
No
What was happening prior to the incident?
Description of the incident? (be as specific as possible)
Did the incident occur as a result of a participant's behaviour of concern?
Yes
No
Was the participant:
(Required)
Trying to communicate a need?
Sensory seeking?
Overstimulated?
Triggered?
Expressing an emotional response to an experience?
Other
Does the participant have a Behaviour Support Plan?
(Required)
Yes
No
If the participant has a Behaviour Support Plan, describe the strategies you implemented in an attempt to avoid the incident?
If two support workers were present (2:1) what was the role of SUPPORT WORKER 1.
If two support workers were present (2:1) what was the role of SUPPORT WORKER 2.
Did you implement an Authorised Restrictive Practice?
(Required)
Yes
No
If you implemented an Authorised Restrictive Practice, please describe:
Did you implement an Unauthorised Restrictive Practice?
(Required)
Yes
No
If you implemented an Unauthorised Restrictive Practice, please describe:
Were there any other witnesses to the incident? If so, please provide details:
Were Emergency Services required? If so, please state Police, Fire or Ambulance:
Do you require any further support as a result of the incident?
Who did you inform of the incident at the time of the incident?
First Name
Last Name
I declare that all information in this incident report to be true and correct and I have answered all questions accurately.
(Required)
Max. file size: 512 MB.
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