Reportable incident
Immediate notification
This reportable incident notification form is approved by the NDIS Quality and Safeguards
Commissioner for the purposes of sections 20 and 21 of the National Disability Insurance Scheme
(Incident Management and Reportable Incidents) Rules 2018 (NDIS Rules).
This form may change over time. We recommend that you access the form directly
from the NDIS Commission website to complete each time a reportable incident occurs.
Privacy
This form seeks to collect information—including personal information—for the purpose of
administering and enforcing the National Disability Insurance Scheme Act 2013 and National
Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.
Please refer to the Privacy Collection Statement and the NDIS Commission’s Privacy Policy at
[Link]/privacy
Security
Once the NDIS Commission receives information from you via e-mail or any other means,
the information is in a secure environment. Your personal information will not be released unless
the law permits it or your permission is granted.
You need to be aware of inherent risks associated with the transmission of information via email
and otherwise over the internet.
If you have concerns in this regard, the NDIS Commission has other ways of obtaining and
providing information including mail, telephone and FilePoint. For advice about how to use FilePoint,
please contact the NDIS Commission at 1800 035 544. If you would like to report an incident through
FilePoint outside of business hours, please email reportableincidents@[Link]
Office use only
RI number Date form received
Date entered in COS Entered by
[Link] Reportable incident Immediate notification 1
Instructions
This form must be completed by registered NDIS providers in SA and NSW within 24 hours of
becoming aware of a reportable incident or allegation occurring in the course of, or in connection
with NDIS supports or services:
• the death of an NDIS participant
• serious injury of an NDIS participant
• abuse or neglect of an NDIS participant
• unlawful sexual or physical contact with, or assault of, an NDIS participant
• sexual misconduct committed against, or in the presence of, an NDIS participant, including grooming
of the NDIS participant for sexual activity.
For reporting unauthorised restrictive practices which do not result in immediate harm, for example,
serious injury, please use the 5 day notification form.
This form should be submitted to the NDIS Commission with copies of documents relating to
the incident. This includes incident report/s, file notes, risk management assessments and/or plans,
participant’s plans relevant to the incident, as well as copies of correspondence between relevant
persons or agencies.
For guidance, please refer to the NDIS Commission’s operational guidelines on reportable incidents
and fact sheets.
The requirement to report to the NDIS Commission does not replace existing obligations on providers
to report to other relevant authorities, including child protection agencies or police.
Once completed, email the form together with relevant documents
to reportableincidents@[Link]
Please note that if you use this form to notify the NDIS Commission of a reportable incident,
there is a further form to be completed within 5 business days of becoming aware of the incident
or allegation. If you have sufficient information to complete the 5 day notification within 24 hours,
you may choose to complete the 5 day notification form.
When completed, this document contains information submitted to the NDIS Quality and
Safeguards Commission (the NDIS Commission) by a third party for the purposes of the National
Disability Insurance Scheme Act 2013 (Cth). The NDIS Commission makes no representations about,
and accepts no liability for, the accuracy of information in this document.
[Link] Reportable incident Immediate notification 2
1. Provider details
Provider name
Provider Registration ID
Provider ABN
Outlet name
Registration group
State
Report completed by
2. Primary contact person
Who is the provider’s primary contact for this incident or allegation?
Title
First name
Surname
Position at provider
Phone number
Email address
Preferred method of contact
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.
Please select
Primary category
Please
Death
Serious
Abuse
Neglect
Unlawful
Sexual ofaselect
Unauthorised
Secondary category of misconduct
Injury
sexual
physical
aperson
person
use
ofacts/offences
awith
of
contact/offences
person
against
with
a Restrictive
disability
disability
with
a person
disability
Practice
with disability
Death
Serious
Abuse
Neglect
Unlawful
Sexual
Unauthorised Please select
If the incident is a death ofof
misconduct
aInjury
ofaperson
sexual
physical
aperson
person
use
ofacts/offences
awith
with
of
contact/offences
person
against
with
a Restrictive
disability
disability
with
a person
disability
disability,Practice
with the
was disability
death anticipated?
Unknown
No
Yes
[Link] Reportable incident Immediate notification 3
4. Incident details
If you have completed an internal incident report please provide it to the NDIS Commission
with this report.
Incident location
Please select
Location type
Residential
In
Specialist
Service
Other
Time and date of the community
outlet
disability
address accommodation
incident/allegation
If date unknown, reason why
Time the NDIS provider became aware of the incident
Date the NDIS provider became aware of the incident
Describe the incident/allegation
What were the circumstances leading up to the incident/allegation?
[Link] Reportable incident Immediate notification 4
5. Impacted person
Who is the person with disability who has been impacted or affected by this incident/allegation?
All reportable incidents must have one person with disability impacted by the incident. If there are
multiple people with disability impacted by an incident, an additional form must be filled in for each.
Title
First name
Surname
NDIS participant number
Please select
Gender
Unspecified
Intersex
Indeterminate
Female
Male
Date of birth
Age at the time of incident
Please select
Primary disability
Please select
Other disability Other
Intellectual
Autism
Cerebral
Psychosocial
Acquired
Visual
Hearing
Multiple
Spinal
Stroke Neurological
Physical
sensory/speech
Cord
Impairment
Impairment
sclerosis
Palsy
Brain
Disability
Injury
Disability
Injury
Intellectual
Autism
Cerebral
Psychosocial
Acquired
Visual
Hearing
Multiple
Spinal
Stroke
Other
Does the person have Physical Injury of concern? Please select
Neurological
sensory/speech
Cord
Impairment
Impairment
anysclerosis
Palsy
Brain
Disability
Injury
Disability
behaviours
Please select Food related
Eating
Property
Physical
Verbal
Harm
Unintentional
Leaving
Refusal
Repetitive
Offending
Sexually
Other to
non
aggression
to
premises
aggression
inappropriate
self
damage
do
or
behaviour
food
unusual
things
self
items
w/out
riskhabits
behaviour
support
How does the person communicate?
Phone number Verbal
Adjusted
Electronic
Picture
Sign
Use
Other
Interpreter
of
language
signing
Gestures
Communication
communication
verbal
communication
language
Email
[Link] Reportable incident Immediate notification 5
6. Subject(s) of allegation
A subject of allegation is a person who has been accused of a reportable incident.
Subject(s) of allegation
Please select
Is there a subject of allegation for this incident?
Unknown
No
Yes
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.
Subject of allegation — worker
Only complete this section if there is a worker who is a subject of allegation.
Title
First name
Surname
Position at time of allegation
Please select
Gender
Unspecified
Intersex
Indeterminate
Female
Male
Date of birth
Phone number
Email
[Link] Reportable incident Immediate notification 6
Subject of allegation — person with disability
Only complete this section if there is a person with disability who is a subject of allegation.
Title
First name
Surname
NDIS participant number
Please select
Gender
Unspecified
Intersex
Indeterminate
Female
Male
Date of birth
Please select
Primary disability
Please select
Other disability Other
Intellectual
Autism
Cerebral
Psychosocial
Acquired
Visual
Hearing
Multiple
Spinal
Stroke Neurological
Physical
sensory/speech
Cord
Impairment
Impairment
sclerosis
Palsy
Brain
Disability
Injury
Disability
Injury
Intellectual
Autism
Cerebral
Psychosocial
Acquired
Visual
Hearing
Multiple
Spinal
Stroke
Other
Does the person have Physical Injury of concern? Please select
Neurological
sensory/speech
Cord
Impairment
Impairment
anysclerosis
Palsy
Brain
Disability
Injury
Disability
behaviours
Please select Food related
Eating
Property
Physical
Verbal
Harm
Unintentional
Leaving
Refusal
Repetitive
Offending
Sexually
Other to
non
aggression
to
premises
aggression
inappropriate
self
damage
do
or
behaviour
food
unusual
things
self
items
w/out
riskhabits
behaviour
support
How does the person communicate?
Phone number Verbal
Adjusted
Electronic
Picture
Sign
Use
Other
Interpreter
of
language
signing
(free
Gestures
Communication
communication
verbal
communication
text)language
Email
Subject of allegation — other
Only complete this section if there is another person who is a subject of allegation.
Title
First name
Surname
Relationship to impacted person
Please select
Gender
Unspecified
Intersex
Indeterminate
Female
Male
Date of birth
Phone number
Email
[Link] Reportable incident Immediate notification 7
7. Immediate action taken
Please select
Have the police been informed of the incident/allegation?
Officers name No
Yes
Police station
Police event number
If the police have not been informed of the incident/allegation, why not?
Please select
Are the impacted person’s family or guardian aware of the incident
Unknown
No
Yes
If not, why hasn’t the impacted person’s family or guardian been contacted?
Please select
If the impacted person is under 18, has the relevant child protection agency been contacted:
If not, why hasn’t the child protection agency been contacted Unknown
NA
No
Yes
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)
[Link] Reportable incident Immediate notification 8
Subject of allegation — worker
This only needs to be completed if there is a worker who is a subject of allegation.
Describe any immediate action that has been taken in respect to the worker who is the
subject of the allegation (for example increased supervision, restriction on current duties,
transferred to other duties, suspended with or without pay).
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).
[Link] Reportable incident Immediate notification 9
8. Risk assessment
If you have completed a risk assessment please provide it to the NDIS Commission with this report.
Please select
Have you undertaken a risk assessment in response to this incident?
If yes, date risk assessment was complete In Progress
No
Yes
Details of risk assessment
If no risk assessment has been undertaken,
what is the reason for not undertaking a risk assessment?
If you have a risk assessment in progress, when was it started?
When do you expect to be finished?
[Link] Reportable incident Immediate notification 10
9. Attachments
Please list all supporting documents you need to submit to the NDIS Commission here.
Attachment name
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.
Full name
Position at organisation
Date
Please save and email the completed form and all attachments to
reportableincidents@[Link]
[Link] Reportable incident Immediate notification 11
