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Incident Report Form
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Incident Number:
Name of Person Reporting Incident:
(Required)
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Contact Number:
(Required)
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Contact Email:
(Required)
Today’s Date is: 21/01/2026
Date of Incident:
(Required)
DD slash MM slash YYYY
Time of Incident:
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Date became aware of Incident:
(Required)
DD dash MM dash YYYY
Address or Location of Incident:
Street Address
Address Line 2
City
State
Post Code
Your role in relation to the incident?
Directly Involved
Witness
Other:
What is your relationship to Sunnyside Australia?
Participant
Participant’s Representative
Employee
Student
Contractor
Volunteer
Other
Program:
Home
Community
Work
Holidays & Respite
Support Coordination
Psychosocial Recovery Coaching
Other:
Incident Type:
Behaviour
Medication
Illness
Accident
Injury (complete Part B too)
Conflict of Interest
Unaccounted / Missing
ANE
Other:
If incident is behavioural in nature select the appropriate box:
Self-harm
Harm to another
Property Damage
Conduct/Misconduct
Illegal Activity
Other:
Did emergency services attend?
No
Yes
If yes, who?
Police
Ambulance
Fire
Name of Leader/Manager Name:
Who was notified about the incident?
Next of Kin / Emergency Contact Name:
Record Attached
Max. file size: 100 MB.
List people involved in or who witnessed the incident:
Name of Person:
(Required)
Email Address:
Contact Phone:
Relationship to Sunnyside Australia:
Did you observe any person filming or recording the incident, or were media present?
Please detail step by step and factually what happened using 5 W’s (who, what, why, where, how). Document in first person.
What did you do / action taken during the incident?
What did you immediately after the incident?
Describe the impact or harm / possible harm caused to any person
What support / assistance do you suggest be provided to person with disability affected by the incident to ensure health and safety?
Knowing what you know now, could anything be done differently to prevent occurrence or reoccurence?
Describe injuries sustained? E.g. burns, lacerations, bruises, broken bones etc.
Please indicate and label the location of injuries sustained on the diagram below:
Types of injuries to record:
BR Bruise
BU Burn
BB Broken Bone
CO Concussion
CL Cut / Laceration
DI Dislocation
FB Foreign Body
FR Fracture
IN Inflammation
IP Internal Pain
OW Open Wound
SP Splinter
RA Rash
P Puncture
O Other:
Has the person been involved in a similar incident before?
If an injury has been sustained, could this be a reoccurrence of a previous injury?
If so, what treatment has previously been given?
If this could be a reoccurrence of a previous injury please specify the date of the last incident:
On this occasion initial treatment/s if any, were given on / / by: e.g. N/A, First Aid, Ambulance, Hospital, Own Doctor etc
Reported / Recorded By:
