This form is to be completed by Zapti contractors to report on any of the following;
Injuries/Incidents that occur
Near Misses that occur
Hazards & Risks that have been identified
NDIS Reportable Incidents that have occured.
WHS & Incident Reporting Form
Notify
Your Email Address
Details of the person involved
Please provide all of the information relating to the person involved here.
First Name
Last Name
Date of Birth
Gender
Female
Male
Prefer not to say
Other
Gender if other:
Contact Mobile Number
Home Address
Details of WHS Report
Date & Time of Incident
Site where Incident Occurred
Reason for Submitting form
Injury/Incident
Near Miss
Reason for Submitting form
Injury / Incident
Near Miss
Hazard / Risk
NDIS – Reportable Incident
Injury / Incident
Include all details of what occured, why you think it occured, what we could do to prevent this from happening again.
If multiple injuries, select all the relevant boxes
Burn
Cut / Laceration
Disc disorder / slipped disc
Fracture
Pain / sprain / strain
No Injury
Psychological Injury / Mental Health
Body part/s affected
Abdomen / Groin
Arms (includes Shoulders and Hands)
Back
Chest
Head
Legs (includes Hips and Feet)
Neck
Not applicable
Other
Body part/s affected if ‘Other’
Cause of Injury or Incident
Client escalation
Contact with hot objects
Hit by moving or stationary object
Manual handling, e.g. lifting, carrying, handling objects
Mental stress
Slip, trip or fall
Unspecified
Please provide all information on the Injury / Incident that occured
Near Miss
Include all details of what occured, why you think it occured, what we could do to prevent this from happening again.
Please provide all information on the near miss that occurred
What can we do to prevent this occurring again?
Hazard / Risk Report
Please use this section to document the Hazard / Risk identified
Please document the Hazard / Risk identified in as much detail as possible
What has been put in place to mitigate the identified hazard / risk?
NDIS – Reportable Incident
Include all details of what NDIS Reportable Incident has occured
Please select category of Reportable Incident
The death of a participant
Serious injury of a participants
Abuse or neglect of a participant
Unlawful sexual or physical contact with, or assault of, a participant
Sexual misconduct, committed against, or in the presence of, a participant, including grooming of the participant for sexual activity
Unauthorised use of restrictive practices in relation to a participant.
Not applicable
Please include all details of the incident including date, time, place and any other information relevant to the conduct.
Submit Incident