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Serious Incident Form

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Serious Incident Form

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A 'serious incident' is where suspicion, complaint, allegation or other evidence is received/obtained about:

the death of, or serious injury to a TAC client or WorkSafe injured worker
a health, safety, abuse or risk to a client/worker, or where there is a failure to meet basic client needs
a provider experiencing significant organisational disruption and executive mismanagement
the ongoing financial viability of the provider
conduct which is, or is potentially, fraudulent, illegal or is engaged in other criminal activity.

For a full listing of reportable incident types please refer to the Incident type drop down box listed below in the Serious incident report form or refer to the Provider Serious Incident Reporting Guidelines.

How to complete

You need to complete and submit this form within 24 hours of becoming aware of a serious incident
Provider Serious Incident Reporting Guidelines

You must fill in all required fields.

Provider Details

Provider Name *

Service Impacted *

Your Name *

Position *

Telephone Number *

Email *

Client Details

Claim No *

First Name *

Surname *

Client’s Family/Guardian Notified *

Y
N

You must notify the client’s family or guardian as soon as possible to explain the serious incident that has occurred and the action being taken to meet the immediate needs of the client.

Name

Date (dd/mm/yyyy) Day Month Year Day Month Year

Does the client require additional support from these services *

Has this been provided *

N/A
Y
N

How have the immediate needs of the client been addressed *

Does the client have a paid family member as a support worker?

Yes
No

Incident Details

Date of Incident (dd/mm/yyyy) <abbr class="sq-form-required-field" title="required">*</abbr> Day Month Year Day Month Year

Time of Incident * Hour Minute Am/Pm Hour Minute

Date incident identified (dd/mm/yyyy) <abbr class="sq-form-required-field" title="required">*</abbr> Day Month Year Day Month Year

Time incident identified * Hour Minute Am/Pm Hour Minute

Place where incident occurred *

Address of where incident occurred *

Incident type *

If "Other" chosen, please provide details

Was there a witness or someone else involved*

Yes
No

Other people involved / witness to incident

First Name * *	Surname * *	Staff or Other * *	Participant/ Witness/ Victim * *	Injured * *	Medical Professional Required * *

Details of Incident

Describe the incident and the immediate response of staff *

Clients recollection of the incident *

Supervisor Report

What actions have been taken and what follow-up actions will be taken in response to the incident *

Other Areas Informed

Line Manager/CEO informed *

Y
N
N/A

Date (dd/mm/yyyy) <abbr class="sq-form-required-field" title="required">*</abbr> Day Month Year Day Month Year

Time * Hour Minute Am/Pm Hour Minute

Name *

Telephone *

Police Contacted

Y
N
N/A

Date (dd/mm/yyyy) <abbr class="sq-form-required-field" title="required">*</abbr> Day Month Year Day Month Year

Time * Hour Minute Am/Pm Hour Minute

Police Officer's Name *

Telephone *

Police Investigation *

Y
N
N/A

Date (dd/mm/yyyy) <abbr class="sq-form-required-field" title="required">*</abbr> Day Month Year Day Month Year

WorkSafe Victoria Notified *

Y
N
N/A

Date (dd/mm/yyyy) <abbr class="sq-form-required-field" title="required">*</abbr> Day Month Year Day Month Year

Coroner Contacted *

Y
N
N/A

Date (dd/mm/yyyy) <abbr class="sq-form-required-field" title="required">*</abbr> Day Month Year Day Month Year

Case Number

By submitting this form you are agreeing all information provided is correct and you are authorised to submit this information

Personal and Health Information

TAC

The TAC will retain the information provided and may use or disclose it to make further inquiries or assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information. Without this information the TAC may be unable to determine entitlements or assess whether treatment is reasonable and may not be able to approve further benefits and treatment. If you require further information about our privacy policy, please contact the TAC

Victorian Workcover Authority

Personal and health information collected by the Victorian WorkCover Authority (VWA) and its Agents on this form is used for the purpose of processing, assessing and managing claims under Victorian workers' compensation legislation to assist with a worker's rehabilitation and return to work and to assist the VWA and its Agents to better manage claims generally.

For the purposes of processing, assessing and managing a claim, the VWA and the Agent of the injured worker's employer may use and/or disclose personal and health information collected in this form or about the worker to each other and to the following types of organisations:

employees, contractors and agents of the VWA and its Agents;
employers of the injured worker;
solicitors, medical practitioners and other health service providers, private investigators, loss adjusters and other service providers acting on behalf of the VWA or the Agent in relation to the claim;
the Accident Compensation Conciliation Service and Medical Panels;
a court or tribunal in the course of criminal proceedings or any proceedings under any of the Acts which the VWA administers;
any other person, organisation or government agency authorised by the individual the information is about, or by law, to obtain the information.

An individual may request access to personal and health information about them collected by the VWA or an Agent by contacting the Agent. Personal and health information collected by the VWA is managed in accordance with the legislation, applicable privacy laws, and the VWA Privacy Policy.

The VWA Privacy Policy is available at the nearest the VWA office or at vwa.vic.gov.au.