Incident Reports / Form
Incident Report Form - Home Care
A factual incident report form for home care providers to record what happened, actions taken, and follow-up.
Template summary
Before you download
- For
- Support workers, coordinators, team leaders, and providers recording incidents in home-based services.
- Use when
- Use after falls, missed services, medication prompt concerns, property damage, behaviour concerns, or other reportable internal incidents.
Who it is for
Support workers, coordinators, team leaders, and providers recording incidents in home-based services.
When to use it
Use after falls, missed services, medication prompt concerns, property damage, behaviour concerns, or other reportable internal incidents.
What this template helps with
A clearer record trail for everyday follow-up
Clear worker notes
Consistent records
Easier follow-up
Example content
Preview the structure before opening the file
Incident details:
- Client name:
- My Aged Care ID or provider ID:
- Date and time:
- Location:
- Reported by:
- Incident type:
- Severity or risk rating:
- Service being delivered:
What happened:
- Factual description - avoid blame or assumptions:
- People present:
- Immediate impact observed:
- Injury, distress, or property damage observed:
- Client statement if relevant:
- Worker statement if relevant:
Immediate response:
- Immediate safety action taken:
- First aid or medical attention arranged:
- Emergency services contacted:
- Coordinator or manager notified:
- Representative or family notified if authorised:
- Service continuity action:
Notification and review screening:
- Internal incident register updated:
- Reportable incident / SIRS screening completed if applicable:
- Open disclosure or apology process considered:
- Related hazard or near miss identified:
- Evidence stored location:
Actions and closure:
- Further review required:
- Root cause or contributing factors:
- Corrective action:
- Responsible person:
- Due date:
- Manager sign-off:
- Date closed:
Review notes
This template is reviewed for plain language, practical field use, and internal consistency. It still needs local review before being used in a provider's own documentation system.