Hazrard Identificarion Report Form

Hazard / risk or near -miss details

Date (DD / MM / YYYY):

Description of hazard/risk:

Risk rate option:

High

Medium

Low

Does any process/procedure exist for this hazard/risk/near miss?

Yes

Identification/ Reporting/ Management

Identification

Reporting

Management

Is the existing process/procedure:

Identification

Reporting

Management

Effective

Partially effective

Ineffective?

Is the risk acceptable?

Yes

Immediate actions and measures to be taken:

Corrective Action (CA)

Description of actions:

CA Deadline (DD / MM / YYYY):

CA Status:

Open

More action required

Closed effectively

Comments by CA responsible person:

Outcomes:

Run training/induction session

Review/amend relevant process/documents

Review/update risk register

Create new procedure

Others:

NDIS consultation required?

Yes

If yes; date of consultation (DD / MM / YYYY):

Report completed by:

Signature

Sign Here

Dear participant: Please complete the following form in the unfortunate event of any incident occurring that did not meet your expectations of care. A formal investigation will commence once we receive the completed form. If you require assistance in the completion of this form, please contact us with provided details. If you want to make anonymous complain, no need to complete your personal details.

Complaint details(to be completed by participant/participant's family)

Is this complaint anonymous:

Yes

If assistance required:

Lawyer yes

Lawyer no

Interpreter yes

Interpreter no

Date of incident (DD / MM / YYYY):

Date of report (DD / MM / YYYY):

Witness name (if applicable)

Worker encountered during the incident:

Description of Complaint:

Immediate actions and measures taken by provider in response to the issue:

Immediate actions and measures were satisfactory?

Yes

Report completed by:

Date (DD / MM / YYYY):

Signature

Sign Here

Investigation to be completed by provider

Preliminary findings:

Identified root causes:

Skills and competence

Workplace Environment

Policies & procedures

Communication

Risk assessment

Others

Required Actions

Description of actions:

Deadline (DD / MM / YYYY):

Status:

Open

More action required

Closed effectively

Outcomes:

Run training/induction session

Review/amend relevant process/documents

Review/update risk register

Create new procedure

Others:

NDIS consultation required?

Yes

If yes; date of consultation: (DD / MM / YYYY):

Complaint resolved?

Yes

Results communicated with Participant?

Yes

Investigation completed by:

Date (DD / MM / YYYY):

Signature

Sign Here