Critical Incident Report

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G_CriticalIncidentReporting_Form_V3

National Disability Insurance Scheme

Northern Territory

Critical Incident Report

Purpose

This form is to be used to record and report the occurrence of a critical incident, including the details of the event, those involved and actions taken by the provider following the incident.

User Instructions

All critical incidents must be notified to Office of Disability 24 hours after the provider becoming aware of the incident. Notification of a critical incident within 24 hours can be in the form of an interim report, made by providing OoD with the below details:

• The name and contact details of the registered NDIS provider.

• The name and DOB of the participant(s) involved in the incident

• A description of the critical incident

• A description of the impact on, or harm caused to, the person(s) with disability

• The immediate actions taken to ensure the health, safety and wellbeing of persons with a disability affected by the incident and whether the incident has been reported to the Northern Territory Police or any other body

• The name and contact details of the person making the notification

Following the interim notification to OoD, a full report is required within 5 business days and is to be submitted on this form to [email protected]

If additional information is required that was not available at the time of, or included within the 5 day report, OoD may at its discretion request a final report from the provider within 30-60 days, on the Critical Incident form.

Incident details

Date of incident: Start date and time ^dd/mm/yyyy hh:mm am/pm

End date and time ^dd/mm/yyyy hh:mm am/pm

Where did the incident occur?

Type of incident

Condition of participant and any other people involved

Describe the injury or harm caused by the incident and medical treatment provided.

If you are not able to provide a full description of the incident within the timeframe, explain why and provide an estimated timeframe for submitting the full report.

CHOOSE ONE OPTION

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About the incident

Summarise the events prior to or leading up to the incident

What occurred during the incident?

Include a full description of the incident, including the people who were there (staff, participants, anyone else who was present or involved), steps taken to manage the incident, and any property involved in the incident. If waiting on further information, briefly describe facts at hand.

What happened after the incident?

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Corrective and restorative actions

Corrective and restorative actions are those acts that a provider makes to support people involved in the incident or to prevent the incident occurring in the future.

Outline what’s been done to ensure the care and support of participants, staff and other relevant persons (offering referral for counselling, offering information on resolution process, etc.). Outline what will be done to reduce the likelihood of the incident reoccurring (changes in policies and procedures, staff training). Include due dates when actions are to be completed. If no action was taken, explain why.

Participant related corrective/restorative actions

For example, participant is referred to medical practitioner for review or assessment/behavior support plan reviewed.

Due date dd/mm/yyyy

Provider level corrective/restorative actions

For example, review of policy, discussion at staff meetings, staff training.

Other Actions

* Any other actions taken (not directly related to the participant) to resolve issues arising from the incident or prevent reoccurrence.

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Participant details

Ensure the participant or their guardian(s) is aware and consents to their details being included in this report.

Participant Given Name:

Participant Family Name:

Gender: Male Female X Indeterminate/Intersex/Unspecified Address:

Suburb, town or community:

Telephone number:

Date of Birth: dd/mm/yyyy

Is a guardian or other legal decision maker appointed for the participant? Yes No

If yes: Public Guardian Community Guardian(s) Joint Guardians (public and community guardian) Other Has the guardian(s) or legal decision maker been notified? Yes No

If the participant is a child, who has parental responsibility?

Parent(s) Minister for Territory Families Shared responsibility between Parent(s) and Minister for Territory Families If the participant is a child, has the responsible party been notified? Yes No

Do you have consent from the participant, their guardians or legal decision makers to share and release the information about them

that is included in this incident report? Yes No

Participant’s primary disability:

Participant’s secondary disability: more than one option may be choosen

Acquired Brain Injury Autism and related disorders Cerebral Palsy

Deafblind (dual sensory) Developmental Delay Down Syndrome ^Epilepsy

Global Developmental Delay ^Hearing

Intellectual Muscular Dystrophy Other Neurological Other Physical Other Psychiatric

Other Sensory

Other - Not Listed (Please Specify)

Schizophrenia

Specific Learning/Attention Deficit Disorder ^Speech

Spinal Cord Injury ^Vision

Does the participant have a positive behaviour support plan (PBSP)? Yes No If No:

PBSP not required

PBSP is currently being developed and due for completion by dd/mm/yyyy

Is the Participant:

NDIS Funded Individual Support Package Funded Block Funded

Does the participant currently have a Disability Coordinator through the Office of Disability? Yes No CHOOSE ONE OPTION

Acquired Brain Injury Autism and related disorders Cerebral Palsy

Deafblind (dual sensory) Developmental Delay Down Syndrome Epilepsy

Global Developmental Delay Hearing

Intellectual

Muscular Dystrophy Other Neurological Other Physical Other Psychiatric Other Sensory

Other - Not Listed (Please Specify) Schizophrenia

Specific Learning/Attention Deficit Disorder Speech

Spinal Cord Injury Vision

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Provider details

Name of provider:

Head office address:

Telephone number:

Report author details:

Name:

Position title:

Date: ^dd/mm/yyyy

Manager or delegate to sign:

Declaration

On behalf of the organisation, I declare as the authorised person, that to the best of my knowledge the information provided in this Critical Incident Report is true and correct.

Yes No

Name: Title: Auto date:

dd/mm/yyyy

Office of Disability use only

Identification number:

Date notification received:

Outcome of review:

Response letter to provider sent

This letter will a include list of actions the provider has committed to in order to prevent re-occurrence. dd/mm/yyyy