Serious incident report form - Disability Services Commission

- Confidential -
Serious Incident Report
Requirement to complete and lodge a serious incident report
The Disability Services Act (1993) requires disability service provider organisations in receipt
of funding from the Disability Services Commission to report to the Commission any death of,
or serious incident to, a person in their care.
This Serious Incident Report form must be completed when a death or serious incident has
occurred. The completed form must be forwarded to the Commission within seven (7) days of
the death or serious incident.
Completed forms should be forwarded to the Executive Director, Corporate Services,
Disability Services Commission, PO Box 441, West Perth, WA 6872, fax:08-9226 2306 or
recordswestperth@dsc.wa.gov.au
What is a serious incident?
A serious incident means one or more of the following:
a) death of a person with disability
b) serious physical injury, or illness of a person with disability
c) where a person with disability poses a serious risk to the health, safety or welfare of
him/herself or others
d) abuse, neglect or exploitation of a person with disability (includes inappropriate or
unauthorised restrictive practices)
e) the charging or conviction of any person of a sexual offence involving a person with a
disability
f) the charging or conviction of any person of an offence involving a person with disability
which may result in imprisonment of the person charged/convicted
g) serious verbal or written complaints received in relation to the service or in relation to the
service provider generally
h) any matter regarding a person with disability in respect of which the service provider must
inform its insurer
i) any referral of any matter or complaint regarding any person with disability, the service or
the service provider generally, to any statutory or investigative body.
NOTE: Serious Incident reports should only be submitted in response to situations
involving injury, illness, abuse, neglect or exploitation that are critical, dangerous,
potentially life-threatening, or that seriously compromise the safety and/or welfare of a
person with disability.
Office Use Only
SIR Number:

1. Details of the person with disability
Name:
Date of birth:
Gender:
Address:
DSC file number (if known):
Disability Services Commission
Serious Incident Report Form
2. Reporting organisation details
Name:
Address:
Contact person:
Telephone:
Fax:
Email:
3. Type of incident (it may be appropriate to tick more than one of the following)
Death □
Serious physical injury □
Serious illness □
Poses serious risk to the health, safety or welfare of him/herself or others □
Abuse □
Domestic violence □
Inappropriate or unauthorised restrictive practices □
Neglect □
Exploitation □
4. Date and time of serious incident
Date:
Time:

5. Details of the incident (summary of the incident in not more than 150 words).
Do not attach any documents to this form
6. Actions and outcomes
In all other situations other than the death of a person with disability,
Have steps been taken to address the person’s health/safety/security?
Has an action plan been developed?
Is the organisation satisfied that the person is no longer at risk?
Is the Chief Executive Officer/Executive Officer aware of the serious incident
Yes / No
Yes / No
Yes / No
Yes / No
7. Signatures
Person completing this report: ___________________________ Date: _____________
CEO/Executive Officer: ________________________________ Date: ______________
DSC use only
Report received by: Date received: Forwarded to:
Note: A copy of the completed SIR form must be inserted in the DSC main file if available.