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Part 1: Reporter Details

Part 2: Incident Details

Date of incident
Time of incident
:

Part 3a: Who was involved

Client details

Client is a:
Victim
Witness
Participant
Was the client injured?
Yes
No
N/A
Was medical attention required?
Yes
No
N/A
Did the client have a seizure?
Yes
No

Part 3b: Who was involved

Staff details

Staff member is a:
Participant
Witness
Victim
Was the staff member injured?
Yes
No
N/A
Was medical attention required?
Yes
No
N/A

Part 3c: Who was involved

Other staff / participants, family members or members of public details

They were:
Participant
Victim
Witness
Were they injured?
Yes
No
N/A
Was medical attention required?
Yes
No
N/A
They were:
Participant
Witness
Victim
Were they injured?
Yes
No
N/A
Was medical attention required?
Yes
No
N/A

Part 4: What happened

Was any property or equipment damaged?
Yes
No
N/A
Was there a hazard?
Yes
No
Was there a spill / hazardous substance?
Yes
No

Is this incident an -

AUTHORISED restrictive practice? (ie: in the PBSP)
Yes
No
N/A
UNAUTHORISED restrictive practice? (ie: not in the PBSP)
Yes
No
N/A
Date
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