Incident Report

Incident Details

Please complete this form within 12 hours of the incident or accident occurring if you were involved in, witnessed, or are reporting the incident.

Incident Type / Person Involved

NDIS Number

Enter the participant’s valid NDIS number if applicable.

If Other, please specify

Date of Incident

Time of Incident

Injured Person’s Name

Incident Location

Name of Person Reporting the Incident

Reporter Phone Number

Reporter Email

Date of Report

NDIS Identify Email

Witness Details – Name of Witness

Witness Phone Number

Witness Email

Witness Description of the Incident

Description of the Incident – Identify who provided the information

Provide details for future investigation.

Description of Injuries or Impact on Person

Complete if applicable.

Actions Taken

Include actions such as first aid, ambulance called, or support provided to the person.