Form: Incident Log

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

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

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

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

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

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

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

PRN Approved [?]
PRN Approved Notes
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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