2. Primary Contact Person

Who is the provider’s primary contact for this incident or allegation?

3. Incident Category:

The categories of incidents are defined in 73Z of the National Disability Insurance Scheme Act 2013 (Cth) and section 16 of the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018. You may wish to include a secondary category if the incident/allegation falls into multiple categories.

Primary Category
—Please choose an option—Death of a person with disabilitySerious injury of a person with disabilityAbuse of a person with disabilityNeglect of a person with disabilityUnlawful sexual acts/offencesUnlawful physical contact/offencesSexual misconduct against a person with disabilityUnauthorised use of a Restrictive Practice

Secondary Category
—Please choose an option—Death of a person with disabilitySerious injury of a person with disabilityAbuse of a person with disabilityNeglect of a person with disabilityUnlawful sexual acts/offencesUnlawful physical contact/offencesSexual misconduct against a person with disabilityUnauthorised use of a Restrictive Practice

If the incident is a death, was it anticipated?
YesNoUnknown

4. Incident Details:

If you have completed an internal incident report please provide it to the NDIS Commission with this report.

Location Type
Residential addressIn the communitySpecialist disability accommodationService outletOther (please type details)

5. Impacted Person:

Gender
—Please choose an option—MaleFemaleIndeterminateIntersexUnspecified

Primary disability
—Please choose an option—AutismIntellectual DisabilityCerebral PalsyPsychological DisabilityOther NeurologicalOther PhysicalAcquired Brain InjuryVisual ImpairmentHearing ImpairmentOther Sensory/SpeechMultiple SclerosisStrokeSpinal Cord InjuryOther

Other disability
—Please choose an option—AutismIntellectual DisabilityCerebral PalsyPsychological DisabilityOther NeurologicalOther PhysicalAcquired Brain InjuryVisual ImpairmentHearing ImpairmentOther Sensory/SpeechMultiple SclerosisStrokeSpinal Cord InjuryOther

Does the person have any behaviours of concern?
—Please choose an option—Food-relatedEating non-food itemsProperty damagePhysical aggressionVerbal aggressionHarm to selfUnintentional self-riskLeaving premises w/out supportRefusal to do thingsRepetitive or unusual habitsOffending behaviourSexually inappropriate behaviourOther

How does the person communicate?
—Please choose an option—Verbal CommunicationAdjusted Verbal LanguageElectronic CommunicationPicture CommunicationSign LanguageOther SigningUse of GesturesInterpreterOther

6. Subject(s) of Allegation:

A subject of allegation is a person who has been accused of a reportable incident. A subject of allegation may be a worker within your organisation or another person, for example a resident living in the same house. There may be more than one subject of allegation. If there is not space on this form, please include additional information in an attachment.

Is there a subject of allegation for this incident
—Please choose an option—YesNo

6.1 Subject of allegation - worker:

Only complete this section if there is a worker who is a subject of allegation.

Gender
—Please choose an option—MaleFemaleIndeterminateIntersexUnspecified

6.2 Subject of allegation - person with disability:

Gender
—Please choose an option—MaleFemaleIndeterminateIntersexUnspecified

7. Immediate Action Taken:

Have the police been informed?
YesNo

Are the impacted person’s family or guardian aware of the incident?
YesNo, please state why by typing into this boxUnsure

If the impacted person is under 18, has the relevant child protection agency been contacted?
YesNo, please state why by typing into this boxUnknownNot applicable

7.1 Impacted Person:

If the incident category is death of a person with disability, this section does not need to be completed.

Describe any immediate support that has been offered/provided to the person with disability impacted by the incident (for example, medical treatment, counselling, access to advocacy, removed source of harm)

7.3 Subject of allegation - person with disability:

This only needs to be completed if there is a person with disability who is a subject of allegation.

Describe any immediate action that has been taken or commenced in respect to the person with disability who is the subject of the allegation (for example, review of staffing, review of behaviour support needs, medical review, assistance to access support person or advocate)

8. Risk Assessment:

If you have completed a risk assessment please provide it to the NDIS Commission with this report.

Have you undertaken a risk assessment?
YesNo

If no risk assessment has been undertaken, what is the reason for not undertaking a risk assessement?

If you have a risk assessment in progress, when was it started?

When do you expect to be finished?

9. Attachments:

Please upload all supporting documents you need to submit to the NDIS Commission here.

File Attachments

10. Declaration:

I declare that:

• I am duly authorised by the organisation identified in this form to submit this reportable incident notification.

• I understand that this information is being collected by the NDIS Quality and Safeguards Commission (NDIS Commission) for the purposes outlined in National Disability Insurance Scheme Act 2013 and the NDIS (Incident Management and Reportable Incidents) Rules 2018.

• To the best of my knowledge, the information provided in this application is true, correct and accurate.

• I acknowledge that the giving of false or misleading information to the Commonwealth is a serious offence under section 137.1 of the schedule to the Criminal Code Act 1995. I understand I need to submit another notification about this incident to the NDIS Commission within 5 business days.

Date