Hazards, incidents, injuries or near miss

Please enter the details of your incident, accident, injury or hazard and ensure that you click on the submit button.

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Date of occurrence*

DD slash MM slash YYYY

Time

Hours

:

Minutes

AM PM AM/PM

Who was involved in the occurrence?*

Client/s

Volunteer/s

Staff member/s

Member/s of the public (outside of the organisation)

Was the occurrence one of the following?

Hazard

Incident/accident

Incident/accident resulting in physical Injury

Near miss

Please select the scenario below describes the incident that has impacted a CLIENT:

Missing consumer

Unreasonable use of force

Psychological or emotional abuse

Unexpected death

Neglect

Stealing or financial coercion by a staff member

Unlawful sexual contact or inappropriate sexual conduct

Inappropriate use of a restrictive practice

Other

Types of occurrences impacting MoWTAS PERSONNEL

Abuse, physical

Abuse, verbal

Animal (e.g., dog bite)

Discrimination or bullying

Fall (no injury)

Injury

harassment

Theft

Vehicle incident

Other

Sexual Harassment is not tolerated at Meals on Wheels. Please complete this form and contact specialist police on 131 444 if you would like to make a criminal complaint.

Sexual harassment in the workplace refers to actions that occur ‘in connection with’ work, including by workers, or by other persons connected to the workplace, including clients, customers, suppliers or visitors.

Was physical force used against a consumer by a member of staff, another consumer or by any other person?

Yes

No

Was there rough handling of a consumer in the delivery of care?

Yes

No

Was a consumer physically attacked or assaulted?

Yes

No

Was the use of force reasonable in the context of providing care? For example, gently touching a consumer to attract their attention or to guide them, or gently touching a consumer to comfort them if they are distressed, or minor disagreements between consumers.

Yes

No

Was the contact reasonable in the circumstances (such as pushing a consumer out of the way of danger)?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires medical treatment to resolve?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires psychological treatment to resolve?

Yes

No

Are there reasonable grounds to report the incident to the police?

Yes

No

The phrase ‘reasonable grounds’ may include scenarios where you are aware of facts or circumstances (alleged or known) that lead to a belief that an incident is potentially or likely to be of a criminal nature and therefore should be reported to police within 24 hours (e.g. if you as the provider suspect the incident involves an indecent assault, or if there is ongoing danger). If you become aware of reasonable grounds at a later time, you must notify the police within 24 hours of becoming aware of those grounds. If you are in any doubt about whether an incident may be of a criminal nature, make a report to the police. Police are the appropriate authorities to investigate and identify whether an incident may involve criminal conduct.

Was a consumer absent when the provider arrived at their home for a scheduled visit?

Yes

No

Did the consumer advise they were leaving their home while services were being provided (and there is no reason for concern about the consumer’s safety or wellbeing)?

Yes

No

Was the consumer receiving care and services in their own home immediately prior to going missing (and is there reason for concern about the consumer’s safety or wellbeing)?

Yes

No

Was the incident related to raised voices to ensure a consumer who has hearing difficulties could hear?

Yes

No

Was there action towards a consumer that includes one of the following behaviours? • Yelling? • Name calling? • Bullying? • Harassment? • Humiliation? • Intimidation? • Taunting? • Making threats? • Making critical or disparaging comments? • Deliberately causing anguish or distress?

Yes

No

Was there an unreasonable refusal to interact with the consumer or acknowledge their presence?

Yes

No

Was a consumer unreasonably refused access to care or services?

Yes

No

Was there an unreasonable restriction of a consumer’s ability to engage socially or otherwise interact with other people during group activities?

Yes

No

Was there an action inflicted on a consumer that knowingly caused, or could reasonably have been expected to cause, anguish or distress (for example, calling a consumer by the wrong name or ignoring a consumer’s expressed and reasonable preferences)?

Yes

No

Was there any other conduct that could reasonably have been expected to have caused a consumer psychological or emotional distress?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires medical treatment to resolve?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires psychological treatment to resolve?

Yes

No

Are there reasonable grounds to report the incident to the police?

Yes

No

The phrase ‘reasonable grounds’ may include scenarios where you are aware of facts or circumstances (alleged or known) that lead to a belief that an incident is potentially or likely to be of a criminal nature and therefore should be reported to police within 24 hours (e.g. if you as the provider suspect the incident involves an indecent assault, or if there is ongoing danger). If you become aware of reasonable grounds at a later time, you must notify the police within 24 hours of becoming aware of those grounds. If you are in any doubt about whether an incident may be of a criminal nature, make a report to the police. Police are the appropriate authorities to investigate and identify whether an incident may involve criminal conduct.

Could the death have resulted from a mistake by the provider, an employee, contractor or someone otherwise engaged by the provider?

Yes

No

Could the death have resulted from a failure of the provider to deliver care and services in line with a consumer’s assessed care needs?

Yes

No

Could the death have resulted from care or services that were poorly managed or not in line with best practice?

Yes

No

Does the incident relate to a suspicion of stealing or financial coercion by an individual who is not a staff member of the provider?

Yes

No

Did a staff member steal money or valuables from a consumer (or is this alleged or suspected)?

Yes

No

Did a staff member financially coerce a consumer or deceive a consumer for financial benefit (or is this alleged or suspected)?

Yes

No

Financial coercion may include coercing a consumer to: Change their will to benefit the staff member. Provide money or items. Buy items for the staff member.

Are there reasonable grounds to report the incident to the police?

Yes

No

The phrase ‘reasonable grounds’ may include scenarios where you are aware of facts or circumstances (alleged or known) that lead to a belief that an incident is potentially or likely to be of a criminal nature and therefore should be reported to police within 24 hours.

Was there conduct by a staff member to unreasonably control the financial affairs of a consumer?

Yes

No

Does the incident relate to missing money and items where a consumer, their family or any other source believes a staff member is responsible?

Yes

No

Does the incident relate to a fully informed consumer freely and willingly buying a small item for a staff member?

Yes

No

Does the incident relate to a fully informed consumer or family member freely and willingly giving a gift to a staff member?

Yes

No

Did money or items go missing where there is a suspicion or allegation that a staff member is responsible?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires medical treatment to resolve?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires psychological treatment to resolve?

Yes

No

Was there a breach of a duty of care owed by the provider or a staff member to provide appropriate care and services to a consumer?

Yes

No

Has the consumer (who has been fully informed of the consequences) chosen not to receive care and services in line with their assessed care needs, and was this documented?

Yes

No

Was there a gross breach of professional standards by a staff member in providing care and services to the consumer (or was this alleged or suspected)?

Yes

No

Was there a failure to assess and monitor a consumer resulting in poor health outcomes or clinical complications?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires medical treatment to resolve?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) the consumer physical or psychological injury or discomfort that requires psychological treatment to resolve?

Yes

No

Are there reasonable grounds to report the incident to the police?

Yes

No

The phrase ‘reasonable grounds’ may include scenarios where you are aware of facts or circumstances (alleged or known) that lead to a belief that an incident is potentially or likely to be of a criminal nature and therefore should be reported to police within 24 hours.

Was the sexual contact or conduct between two consumers?

Yes

No

Did both consumers have the capacity to consent to sexual relationships and/or activities?

Yes

No

Did both consumers consent to the sexual contact or conduct at the time of the incident?

Yes

No

Was there sexual contact or conduct between a volunteer, staff member (or any other person who provides care or services for the provider) and a consumer (or was this alleged or suspected)?

Yes

No

Was there touching of the consumer’s genital area, anal area or breast in a way that was not necessary to provide care (or was this alleged or suspected)?

Yes

No

Was there any sexual contact without the consumer’s consent (including where the consumer was not able to give consent)?

Yes

No

Was there conduct of a sexual nature without consent, including any acts of indecency, sharing of intimate images (including of the consumer), or other inappropriate sexual conduct (or was this alleged or suspected)?

Yes

No

Was there unlawful sexual contact between a consumer and any other person (or was this alleged or suspected)?

Yes

No

Was there grooming or coercion of the consumer for sexual purposes (or was this alleged or suspected)?

Yes

No

Was a restrictive practice used or applied to a consumer (or was this alleged or suspected)?

Yes

No

Restrictive practices are defined as ‘any practice or intervention that has the effect of restricting the rights or freedom of movement of a residential care recipient’, including: Chemical restraint, Environmental restraint, Mechanical restraint, Physical restraint, and Seclusion.

Were all alternative best practice strategies exhausted prior to the use of restrictive practice, and were these strategies documented (including the reasons why the strategies were not successful)?

Yes

No

Was there documentation in the consumer’s care plan about: The consumer’s behaviours that were relevant to the need for the use of the restrictive practice; The alternative strategies that were used (if any) before the use of the restrictive practice; The reasons the restrictive practice was necessary; The assessment conducted by the approved health practitioner.

Yes

No

Was the restrictive practice used in the least restrictive form, and for the shortest time necessary, to prevent harm to the care recipient or other persons?

Yes

No

Did you obtain informed consent from the consumer or their substitute decision maker before the restrictive practice was used?

Yes

No

Was the likely impact of the restrictive practice on the consumer considered before the restrictive practice was used?

Yes

No

While the restrictive practice was being used, was the consumer regularly monitored for: signs of distress or harm, side effects and adverse events, changes in wellbeing, independent functions, and ability to undertake activities of daily living?

Yes

No

While the restrictive practice was being used was it regularly reviewed with a view to removing it as soon as possible?

Yes

No

Did the use of the restrictive practice comply with: the requirements (if any) of the law of the state or territory in which it was used? the Aged Care Quality Standards? the Charter of Aged Care Rights?

Yes

No

Was the restrictive practice necessary to use in an emergency situation to prevent harm to the consumer or others?

Yes

No

Was the restrictive practice used in response to the consumer’s documented behaviour changes or behaviours of concern?

Yes

No

Was a behaviour support plan in place?

Yes

No

Did an approved health practitioner, who has day-to-day knowledge of the consumer assess and document that there is a risk of harm to the consumer or another person, and that the use of a restrictive practice was necessary?

Yes

No

For chemical restraint the assessment and prescription must be made by a medical practitioner or nurse practitioner with day-to-day knowledge of the consumer.

Was the use of the restrictive practice proportionate to the emergency situation?

Yes

No

Was the consumer’s restrictive practices substitute decision maker informed about the restrictive practice as soon as practical after the restrictive practice was applied in the emergency situation, and was this documented?

Yes

No

While the restrictive practice was being used, was the consumer regularly monitored for: signs of distress or harm, side effects and adverse events, changes in wellbeing, independent functions, and ability to undertake activities of daily living?

Yes

No

Did you revert to usual policies and practices regarding restrictive practices use as soon as the emergency was over, including: removing or reducing the restrictive practice, assessment, consideration of alternative strategies, and updating the consumer’s behaviour support plan and care and services plan?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) a consumer physical or psychological injury or discomfort that requires medical treatment to resolve?

Yes

No

Did the incident cause (or could it reasonably have been expected to have caused) a consumer physical or psychological injury or discomfort that requires psychological treatment to resolve?

Yes

No

Are there reasonable grounds to report the restrictive practice to the police?

Yes

No

The phrase ‘reasonable grounds’ may include scenarios where you are aware of facts or circumstances (alleged or known) that lead to a belief that an incident is likely to be of a criminal nature and therefore should be reported to police.

Priority 1 reportable incident. Based on the information you have provided it appears that this incident is an Inappropriate use of restrictive practices – MoWTAS will use this completed form to report this incident through the My Aged Care Provider Portal within 24 hours of becoming aware of the incident.

Priority 2. Based on the information you have provided it appears that this incident is an Inappropriate use of restrictive practices – – MoWTAS will use this completed form to report this incident through the My Aged Care Provider Portal within 30 hours of becoming aware of the restrictive pratice.

Not reportable. Based on the information you have provided regarding restrictive practice, it appears that your incident is not a reportable incident under the SIRS. Please complete the rest of this form and click on submit. We will record this on our Incident Management System and follow up internally.

Priority 1 reportable incident. All incidents involving Unlawful sexual contact or inappropriate sexual conduct are Priority 1 reportable incidents. MoWTAS will use this completed form to report this incident through the My Aged Care Provider Portal within 24 hours of becoming aware of the incident. Remember where an incident, allegation or suspicion involves unlawful sexual contact or conduct of a criminal nature, this must also be reported to police immediately. If you are in any doubt about whether an incident is of a criminal nature, make a report to the police. Police are the appropriate authorities to investigate and identify whether an incident may involve criminal conduct.

Based on the information you have provided it appears that this is not a reportable incident under the SIRS. Consumers have the right to make choices about their personal and social life, including the right to sexual freedom and to give and receive affection. Under the Quality Standards, you are required to support consumers to exercise choice and independence, including to make connections with others and maintain relationships of choice, including intimate relationships. These rights and freedoms apply equally to consumers with a mental or cognitive impairment. Please complete the rest of this form and click on submit so that we can record this incident on the MoW register.

Priority 1 reportable incident. Based on the information you have provided it appears that this incident is a Neglect – MoWTAS must report this incident to the Aged Care Quality and Safety Commission within 24 hours of becoming aware of the incident. Please complete this form and notify a MoWTAS Client Service Officer.

Priority 2 reportable incident. Based on the information you have provided it appears that this incident is a Neglect – MoWTAS must report this incident to the Aged Care Quality and Safety Commission within 30 days of becoming aware of the incident. Please complete this form and a Client Service Officer will follow up with the relevant parties.

Not reportable. Based on the information you have provided it appears that your incident is not a reportable incident under the SIRS. Please complete the rest of this form and click on submit. We will record this on our Incident Management System and follow up internally.

Priority 1 reportable incident. Based on the information you have provided it appears that this incident is a Stealing or financial coercion by a staff member – MoWTAS must report this incident to the Aged Care Quality and Safety Commission within 24 hours of becoming aware of the incident. Please call Penny Sears at State Office after completing this form.

Priority 2 reportable incident. Based on the information you have provided it appears that this incident is a Stealing or financial coercion by a staff member – MoWTAS must report this incident to the Aged Care Quality and Safety Commission within 30 days of becoming aware of the incident. Please call Penny Sears at State Office after completing this form.

Not reportable. Based on the information you have provided it appears that your incident is not a reportable incident under the SIRS. Please complete the rest of this form and click on submit so that we can record this incident on the MoW register.

Based on the information you have provided it appears that this incident is an unexpected death reportable incident. Contact Police, Branch Coordinator and please follow up with a phone call to State Office. MoWTAS must report unexpected deaths to the Aged Care Quality and Safety Commission within 24 hours of you becoming aware of the incident. MoWTAS must report the incident through the My Aged Care Provider Portal.

Based on the information that you have provided it appears that this death is not a reportable incident under the SIRS. HOWEVER, Police, Branch Coordinator and State Office should still be contacted. Please complete the rest of this form and click on submit.

Priority 1 reportable incident. Based on the information you have provided it appears that this incident is a Psychological or emotional abuse – Contact State Office immediately so that we can report this incident to the Aged Care Quality and Safety Commission within 24 hours.

Priority 2 reportable incident. Based on the information you have provided it appears that this incident is a Psychological or emotional abuse – Please ensure that all fields in this form are completed before clicking on submit so that State Office can follow up with the Aged Care Quality and Safety Commission within 30 days.

Based on the information you have provided it appears that your incident is not a reportable incident under the SIRS. Please complete the rest of this form and submit, we will enter this incident into our Incident Management System

Priority 1 reportable incident. Based on the information you have provided it appears that this incident is an Unreasonable use of force – Complete this form and follow up with a phone call to State Office. Incidents must be reported to the Aged Care Quality and Safety Commission within 24 hours of you becoming aware of the incident.

Priority 2 reportable incident Based on the information you have provided it appears that this incident is an Unreasonable use of force – Please complete the rest of this form and click on submit. Priority 2 incidents must be reported by MoWTAS to the Aged Care Quality and Safety Commission through the My Aged Care Provider Portal within 30 days of you becoming aware of the incident.

Not reportable. Based on the information you have provided it appears that your incident is not a reportable incident under the SIRS. Please complete the rest of this form and click on submit. This incident will be recorded in our Incident Management System

Reportable incident. Based on the information you have provided it appears that this incident is a Missing consumer reportable incident. Please complete this form, contact Police, Branch Coordinator and State Office. Unexplained absences from care must be reported to the Aged Care Quality and Safety Commission by MoWTAS within 24 hours

Not reportable. Based on the information you have provided it appears that your incident is not a reportable incident under the SIRS. Please complete the rest of this form and click on submit. We will record this on our Incident Management System.

Location of the occurrence*

Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Name and contact number of client/s*

Name and contact number of volunteer/s*

Name/s and contact number of staff member*

Name and contact details of member/s of the public (outside of the organisation)

Name and contact number of any witnesses

Registration number*

Vehicle Model*

Driver's licence number*

Driver licence expiry date*

MM slash DD slash YYYY

What date or year did you first get your licence?

Did the vehicle incident involve one of the following?*

Meals on Wheels Vehicle

Volunteer vehicle

MoWTAS vehicles only, please select one of the following.*

Motor vehicle mechanical issues

Motor vehicle accident

Motor vehicle mechanical issues (MOW vehicles only) Call RACT Roadside Assistance 132 722, quote client number and vehicle registration number. Ensure photos are provided with this incident report.

Motor vehicle accident, if a tow truck is required, windscreen replacement or vehicle repairs (MOW vehicles only) contact Steadfast 03 6231 3360. Quote CGU insurance policy number and expiry. Organise to get MOW vehicle to a repairer to provide a quote for repairs. Contact Steadfast to organise a hire vehicle while repairs are being undertaken. Once you have completed this form, copy and paste the following link into your browser to complete the Steadfast insurance claim form, download and email it to amber@stib.com.au https://mowtas.org.au/wp-content/uploads/2024/03/Motor-Vehicle-Claim-Form.pdf

Motor vehicle accident (volunteer vehicle) The volunteer will claim the accident through their own insurance policy. MOW will contribute a maximum of $500.00 towards the volunteer’s excess. Ensure photos are provided with this incident report.

Area of damage / Body part injured*

What property damage, if any, was caused?*

Description of hazard, incident, injury or near miss.*

State exactly how accident, incident or injury occurred. If you have noticed a hazard, please describe.

Action taken*

e.g., was first aid required, bandage or ice applied? Did you have to call on any external bodies for assistance?

External bodies contacted or to be contacted.

Aged Care Quality and Safety Commission

Ambulance

Counselling services

Doctor

Fire department

Insurer – MoWTAS

Insurer – private vehicle

Police

RACT Roadside

Other

Other

Preventative action plan*

Name*

First Last

Email

If you would like a copy of this form, please enter your email address here.

Upload photos of occurrence here

Drop files here or Select files

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This form is required to make a workers compensation claim for your work-related injury.

It includes a worker section for you to complete, and a section for your employer to complete. 

Link to Workers Compensation form

You must notify WorkSafe Tasmania if any of the following incidents have occurred in the workplace:

• a death, or
• someone suffers a serious injury or illness, or
• a dangerous incident
• someone contracts certain infections or occupational zoonoses.

Link to Worksafe Tasmania form

Electric shocks must also be reported to TasNetworks on 13 2004.