Critical Incident Report Form

Critical Incident Report Form
A critical incident may involve threats to life, the health, safety and/or wellbeing of clients, provider staff or other relevant persons, serious injury or death

All disclosed information must be provided in an unidentified manner. This includes refraining from disclosure of any parties' full legal names

For more information on Critical Incidents and Critical Incident Reporting please see Critical Incidents Reporting Procedure - Commissioned Services
SECTION 1: REPORTER'S DETAIL
Reporting Organisation:*
Name of person completing this form*

First NameLast Name
Location:*
(Include address, where applicable.)
Contact number:*
Email*
example@example.com
Type of critical incident that is being recorded*

Eligible data breachDeath or likely permanent harm of a current or recent clientClinical error causing harm to clientNear miss (clinical error with potential to cause harm but did not actually eventuate in harm)Situational circumstances that placed a consumer in immediate life-threatening dangerSerious acts of aggression towards self, consumers carers, or staff (that may result in physical or psychological harm)Professional misconduct of staff member or contracted private practitionerOther
SECTION 2: INCIDENT DETAIL
Date and time of incident:*

DayMonthYear

MinutesAM/PM Option
Date you were informed of incident

DayMonthYear
Place where incident occurred*

Client's home settingProvider’s service setting or officeVirtuallyOther
SECTION 3: PERSONS INVOLVED
Primary person impacted by incident*

ClientStaffCarerMember of the publicOther
Other parties involved or impacted by incident*

ClientStaffCarerMember of the publicOther
Medical / Counselling required*

YesNo
Does this incident involve a shared care arrangement with other providers? *

YesNoUnsure
Details of the providers delivering shared care arrangements
Was a minor present or impacted by the incident/s? *

YesNoUnsure
Was any person impacted by the incident/s culturally identified as being Aboriginal and/or Torres Strait Islander? *

YesNoUnsure
SECTION 4: CRITICAL INCIDENT

(Include all relevant circumstances and information leading up to the incident, whether the incident was witnessed)
Details of what occurred for this to be a critical incident
All disclosed information must be provided in an unidentified manner. This includes refraining from disclosure of any parties full legal names.
SECTION 5: CRITICAL INCIDENT SEVERITY RATING
What is the critical incident severity rating?
For more information on Critical Incidents and Critical Incident Reporting please see Critical Incidents Reporting Procedure - Commissioned Services
SECTION 6: CRITICAL INCIDENT RESPONSE
Actions taken to date
Follow up actions planned:
Privacy Collection Notice

As a member of the commissioned Service/ funded service provider, your contact details (including your organisation, your name, location and telephone number) are collected by the DDWMPHN for records and contact purpose. We will only use your contact details and any other personal information that you give us for this purpose and will not disclose it without your consent, except where we are required to do so by an Australian law or a court/tribunal order.

For further information on our privacy policy and our complaints process please read our privacy policy on our website.

Last updated: 10 September 2024
Should be Empty:

Critical Incident Report Form

SECTION 1: REPORTER'S DETAIL

SECTION 2: INCIDENT DETAIL

SECTION 3: PERSONS INVOLVED

SECTION 4: CRITICAL INCIDENT

SECTION 5: CRITICAL INCIDENT SEVERITY RATING

SECTION 6: CRITICAL INCIDENT RESPONSE

Privacy Collection Notice