Client Incident Report Form
Please note it is important that all incidents are reported to Austra Health via telephone as soon as practicable. Then complete this form to formally report incidents involving and/or impacting upon clients.
Name of on-hired employee:
Name of client:
Date of incident:Time of incident: AM PM
If you did not see the incident:
Date you were first told about it:Time first told: AM PM
Address/location of incident:
Type of incident: Injury Assault/Violence/Aggression Motor vehicle accident Near miss
For incidents involving assault, violence or aggression please tick one box below which best describes the incident: *‘Other’ refers to those who are not clients, on-hired carers but who were involved (such as family or friends of client or stranger).
Client to Client Client to Other *
Client to On-hired Carer Other to Client *
On-hired Carer to Client
Who was involved? Please fill out a section for each person involved:
First Name:Surname: Contact Number:
Sex:Male FemaleAboriginal/Torres Strait Islander:Yes No
Involvement: Participant Witness VictimType: Client Carer Other
Injured:Yes NoMedical Treatment Required:Yes No
First Name:Surname: Contact Number:
Sex:Male FemaleAboriginal/Torres Strait Islander:Yes No
Involvement: Participant Witness VictimType: Client Carer Other
Injured:Yes NoMedical Treatment Required:Yes No
First Name:Surname: Contact Number:
Sex:Male FemaleAboriginal/Torres Strait Islander:Yes No
Involvement: Participant Witness VictimType: Client Carer Other
Injured:Yes NoMedical Treatment Required:Yes No
First Name:Surname: Contact Number:
Sex:Male FemaleAboriginal/Torres Strait Islander:Yes No
Involvement: Participant Witness VictimType: Client Carer Other
Injured:Yes NoMedical Treatment Required:Yes No
First Name:Surname: Contact Number:
Sex:Male FemaleAboriginal/Torres Strait Islander:Yes No
Involvement: Participant Witness VictimType: Client Carer Other
Injured:Yes NoMedical Treatment Required:Yes No
Details of Carer or Others:
If treatment was required please indicate which:
First Aid Doctor (Doctors name )
Ambulance Hospital (Name of Hospital )
What happened?
Described the incident and the immediate response of carers:
This section should be a brief, factual account of the incident. Include impact on client; who was involved; how, where and when the incident occurred; who did what; who (if anyone was injured and the nature and extent of injuries).
Were the police involved? Yes No
If yesplease attach a copy of the police report
Was any property or equipment damaged? YesNo
If yes, please provide details of the damage:
Signature of reporter: Date:
Please send completed form to:
AHNAT Client Incident Report Form AHNAT AF 120-163Controlled Document – Rev 1 – Dec 16