Incident Report Form

The purpose of this form is to report all incidents that occur during RLA supports.

An incident is defined as:

(a) Anything that has, or could have, caused harm to a person with disability receiving supports or services; and
(b) acts by a person with disability that happen in connection with the provision of supports or services and that have caused serious harm, or a risk of serious harm, to another person; and
(c) Reportable incidents that are alleged to have occurred in connection with the provision of supports or services.

Date of incident *Date of when the incident was brought to our attention if unaware of the exact date

Time of incident *Time of when the incident was brought to our attention if unaware of the exact time

Details of the incident, including lead up, impact, and what steps you took to manage the incident *Use factual, unemotional language. State what happened without judgement. Include location.

Name of person completing form *

Are you a staff member? *

YesNo

Are you a support worker? *

YesNo

Staff position of the person completing the form

Email (optional)Fill this out if you would like to receive a copy of this incident form when submitted

Would you like to be contacted about this incident?

YesNo

Which parties were involved? *

YourselfOther staff member(s)Participant(s)Other(s)

Tick all that apply

This incident did not involve a participant [select Participant(s) above if this is not the case] *

Other staff member name(s) *

Name of participant(s) *

Do the participant(s) have a RLA Support Facilitator? *

YesNo

Name of other parties involved *

Did the incident involve any of the following: *

The death of a person with a disabilitySerious injury of a person with a disabilityMinor injury of a person with a disabilityAbuse or neglect of a person with a disabilityUnlawful sexual or physical contact with; or assault of a person with a disabilitySexual misconduct against or in the presence of a person with a disability; including grooming of the person for sexual activityThe use of a restrictive practice in relation to a person with a disabilityWorkplace injury and/or harm to a staff memberOther

Tick all that apply

Please specify the type of incident *

Draw the body where the injury occurred *

Clear drawing

If it cannot be accurately displayed on the picture, draw outside of the body

Attach any evidence

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Photos or Documents