Company Incident Management System (CIMS)

Please complete this form for ALL incidents, including minor incidents to ensure our records are accurate.

Your Name

Your Contact Email

Were you involved or did you witness the incident?

Involved Witness Neither

Name	Role	Involvement	Injury	Medical Attention
	Customer Staff Member Volunteer Contractor Other Party	Impacted Person Witness Initiator/Aggressor	Death Injury Near Miss None of the above	Hospital First Aid only First Aid and Hospital Nil
	Customer Staff Member Volunteer Contractor Other Party	Impacted Person Witness Initiator/Aggressor	Death Injury Near Miss None of the above	Hospital First Aid only First Aid and Hospital Nil
	Customer Staff Member Volunteer Contractor Other Party	Impacted Person Witness Initiator/Aggressor	Death Injury Near Miss None of the above	Hospital First Aid only First Aid and Hospital Nil
	Customer Staff Member Volunteer Contractor Other Party	Impacted Person Witness Initiator/Aggressor	Death Injury Near Miss None of the above	Hospital First Aid only First Aid and Hospital Nil

Reported by

In Person Phone call Text Phone call + Text

Incident Type (Primary)

Absconding Abuse/Neglect - Exclusion Abuse/Neglect - Financial Abuse/Neglect - Other (please specify) Abuse/Neglect - Physical Abuse/Neglect - Sexual Abuse/Neglect - Social Abuse/Neglect - Verbal Aggression - Physical Aggression - Physical (PRN Administered) Aggression - Verbal Aggression - Verbal (PRN Administered) Agitation / Anxiety Breach of LiveBetter policy or procedure Criminal activity (held in custody) Customer behaviour attracting concern Customer death - End of Life Palliative Care Customer death - in Hospital Customer death - in LiveBetter care Customer death - Unforeseen death Customer illness Customer injury Damage - Equipment Damage - Fire, explosion, etc. Damage - IT/Data Damage - Other (please specify) Damage - Property Disclosure of contentious information by customer Disclosure of contentious information by staff/volunteer/stakeholder Distress Inappropriate workplace/staff behaviour Infection control incident Information Security Manual Handling Medication - Administer PRN Medication - Customer Refusal Medication Error - Administration Medication Error - Dispensing Medication Error - Documentation Medication Error - Handling Medication Error - Other (please specify) Medication Error - Storage Near miss incident Other (please specify) Possession of Illicit Substances Potential risk to customer Security - Breach / Issue Self Harm Situation requiring police involvement Slips, Trips, Falls Staff/volunteer/stakeholder illness Staff/volunteer/stakeholder injury Suicide Ideation Theft Unauthorised use of a restrictive practice Unscheduled customer absence Vehicle - Accident Vehicle - Damage Vehicle - Incident Vehicle - Other (please specify) Work Environment - Environment Work Environment - Equipment Work Environment - Incident Work Environment - Other (please specify)

If other, please specify

If other, please specify

Incident Severity	Low Medium High Critical
Click here for an explanation of each incident severity

Incident Date

Pick

Team

ARC: Carer Gateway ARC: Community Care - Bathurst, Cowra, Parkes, Forbes, Dubbo ARC: Community Care Albury ARC: Community Care Broken Hill ARC: Community Care Far West ARC: Community Care Griffith / Leeton ARC: Community Care Narromine, Wellington, Dubbo ARC: Community Care Orange Millthorpe Molong ARC: Community Care Wagga Wagga / Narrandera ARC: Day activities - Queensland ARC: Emu Park ARC: Longreach ARC: Mackay ARC: Mildura ARC: Monto ARC: Out of Hospital care ARC: Rockhampton ARC: Support Coordination ARC: Wide Bay ARC: Yeppoon ARCS: Gladstone CFS: Family Services CFS: HIPPY CFS: Preschools CIMs Support ( DO NOT USE ) Cli: Clinical Services QLD Corporate Dis: Accommodation 1 Nile Street Orange Dis: Accommodation 24 Kamdell Place Orange Dis: Accommodation Building B 14 Ralston Drive Orange Dis: Accommodation / Drop in Support Nambucca Dis: Accommodation 1-7 Queen Street, Dubbo Dis: Accommodation 101 Howick St Bathurst Dis: Accommodation 111 Rossi Drive Clifton Grove Dis: Accommodation 112-114 Kearneys Dr Orange Dis: Accommodation 12 Birchgrove Drive Orange Dis: Accommodation 12 Romano Drive, Orange DIS: Accommodation 13 Beetson Boorooma Dis: Accommodation 13 Thomas Smith Place Dubbo Dis: Accommodation 137 Bourke St, Dubbo Dis: Accommodation 14 a Belwood Rd Dis: Accommodation 14 Belwood Rd Dis: Accommodation 15 Apprentice Ave Dis: Accommodation 15 Bourkelands Drive, Wagga Dis: Accommodation 17 Lisbon Circuit Orange Dis: Accommodation 171 Ophir Road Orange Dis: Accommodation 171A Ophir Rd Orange Dis: Accommodation 2 Knight Pl, Bathurst Dis: Accommodation 21 Wombine Cres, Wagga Dis: Accommodation 239 Dalton St Orange Dis: Accommodation 25 Woodbridge St, Killara Dis: Accommodation 298 Myall Street Dubbo Dis: Accommodation 3 Geebung place, Orange Dis: Accommodation 305 Darling St Dubbo Dis: Accommodation 46 Bletchington Street Orange Dis: Accommodation 5 Juniper Pl Orange Dis: Accommodation 52 Kenna Street Orange Dis: Accommodation 54 Moonstone Dr Orange Dis: Accommodation 58 Eisenhauer Dr, Thurgoona Dis: Accommodation 68 Cuthbert St, Killara Dis: Accommodation 68 Diamond Dr, Orange Dis: Accommodation 8 McIntosh Place - Orange Dis: Accommodation 9 Roper St, Albury Dis: Accommodation Build A - 22 Rifle Range Rd Orange Dis: Accommodation Build B - 22 Rifle Range Rd Orange Dis: Accommodation Building A 14 Ralston Drive Orange Dis: Accommodation Campbell St, Wandal Dis: Accommodation Fitzroy St, Rockhampton Dis: Accommodation Glencoe Rockhampton Dis: Accommodation Tantoon Circuit, Wagga Dis: Accommodation Teak Close, Wagga Dis: Active Participation ADE Mid North Coast Dis: Active Participation Bundaberg Dis: Active Participation Emu Park Dis: Active Participation Gladstone Dis: Active Participation Longreach Dis: Active Participation Mackay Dis: Active Participation Rockhampton Dis: Active Participation Yeppoon Dis: Community Access Bathurst Dis: Community Access Bourke/L Ridge Dis: Community Access Broken Hill Dis: Community Access Cobar Dis: Community Access Far West Dis: Community Access Nambucca Dis: Community Access Nyngan Dis: Community Access Orange Dis: Community Access Wagga Dis: Day Program Central West Dis: Drop in Support - Albury Office Dis: Drop in Support - Bathurst Dis: Drop in Support - Gypsum St - Broken Hill Dis: Drop in Support - Orange DIS: Drop in Support - Wagga Dis: Respite 40 Wright St Broken Hill Dis: Respite Bourke/L Ridge Dis: Respite Far West Dis: Respite Nyngan Dis: Skills4Life DIS: STA 2 Lyon Close Bathurst Dis: Vocational Central West Dis: Vocational Far West Dis: Vocational Services - Gypsum St - Broken Hill Finance Home Mods Transport - Assisted School Transport Transport - Commercial Transport - Community Transport - Community - Broken Hill Transport - Community - Dubbo Transport - Community - Nyngan Transport - Community - Orange Transport - Fleet Unknown - Location

Business Stream

Active Participation Aged & Community Services Caring for your Buraay Clinical Services Community Transport CSH Disability Services Family Connections Finance HeadSpace Home Mods HR ICT Leap Frog OOHC Pre Schools Skills for Life WHS zz_deprecated Aug2022

Emergency services contacted?

Police Ambulance Fire Brigade

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Nature of injury/illness:

Injuries of the head or skull Fractures or breaks Wounds or lacerations i.e. Cuts Burn Injury to Nerves or spine Injury to muscles, tendons, joints or ligaments Other COVID-19

Bodily location of injury/illness:

Forehead Head (left side) Head (right side) Head (back) Ear (left) Ear (right) Eye (left) Eye (right) Nose Cheek (left) Cheek (right) Mouth Chin Neck (front) Neck (left) Neck (right) Adam's apple Neck (back) Shoulder (left) Shoulder (right) Thorax Chest Back Breast (left) Breast (right) Abdomen Umbilicus Penis/Vagina Arm (left) Elbow (left) Forearm (left) Wrist (left) Hand (left) Fingers (left hand) Arm (right) Elbow (right) Forearm (right) Wrist (right) Hand (right) Fingers (right hand) Thigh (left) Knee (left) Calf (left) Ankle (left) Foot (left) Toes (left foot) Thigh (right) Knee (right) Calf (right) Ankle (right) Foot (right) Toes (right foot) Non-Physical Locations Unspecified Location

What was the cause of the injury/illness?

Falls,trips and/or slip Hitting objects with a part of the body Body hit by another person or object Injury to sense Heat, electricity and other environmental factors Chemicals and other substances Biological factors Mental stress Other Manual Handling

Was any plant, equipment, substance or thing involved in the injury/illness?

Machinery and fixed plant Mobile plant and transport Powered equipment, tools and appliances Non-powered handtools, appliances and equipment Chemicals and Chemical products Materials and substances Environmental agencies Animal, Human and biological agencies Other

Describe the injury in your own words: