Incident / Injury Report - Amica Community Services

Report / provider details

Report completed by *Enter the name of the person is writing the report

Position of person reporting *What is the role of the person writing the report?

Phone Number *Phone number of person reporting

Email Address *Email address of person reporting

Date of incident *

Enter the exact date of incident

Time of incident *

Hours

Minutes

Enter the exact time of incident

Primary category of incident *

Specify the primary category

Secondary category of incident *

Specify the secondary category

Incident location *Enter address of where the incident happened

Location type *

Specify the location type

Incident description *Describe what happened in detail and how the situation unfolded (who was involved, what has occured, and why it occurred)

Incident circumstancesBriefly describe what were the circumstances leading up to the incident (optional)

Name *Enter the name of the participant harmed by the incident

Paticipant NDIS number *Enter the NDIS number of the participant impacted

Phone *Enter the phone number of the participant harmed by the incident

Participant Email AddressEnter the email address of the participant harmed by the incident

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Was there any witnessesNoYes

Witnesses Group

Name *Enter the witness name

Phone *Enter the witness phone number

Email AddressEnter the witness email address

First aid provided *YesNo

First aid detailsProvide details about the first aid provided

Emergency Services ContactedYesNo

Was the incident reported to relevant authorities *YesNo

Was the participant's guardian/advocate informed? *YesNo