Serious incident and restrictive practice form

Do you need to notify the TAC about

Serious incidentRestrictive pratice

For this restrictive practice, are you notifying the TAC about *

An intention to use a restrictive practiceThe emergency use of a restrictive practiceThe use of a prohibited practice

Restrictive practice form

Please note that the TAC will report the use of a prohibited practice to the Victorian Senior Practitioner.

Serious incident form

A 'serious incident' is where suspicion, complaint, allegation or other evidence is received/obtained about:

the death of, or serious injury to a TAC client or WorkSafe injured worker
a health, safety, abuse or risk to a TAC client or WorkSafe injured worker, or where there is a failure to meet basic client needs
a provider experiencing significant organisational disruption and executive mismanagement
the ongoing financial viability of the provider
conduct which is, or is potentially, fraudulent, illegal or is engaged in other criminal activity.

For a full listing of reportable incident types please refer to the Incident type drop down box listed below in the Serious incident report form or refer to the Provider Serious Incident Reporting Guidelines.

How to complete

You need to complete and submit this form within 24 hours of becoming aware of a serious incident.

You must fill in all required fields.

Provider details

Provider name *

Service impacted *

Attendant careShared Supported AccommodationRIPLCISS

Which Regulators are you registered with? *

Victorian Social Services RegulatorNDISNot registered

If registered, please ensure that you also follow incident reporting guidelines for the regulator you are registered with.

Your name *

Your position *

Phone number *

Email *We'll send a copy of this form to this email address.

Client details

Is your client a *

TAC clientWorkSafe injured worker

TAC client details

WorkSafe injured worker details

TAC claim number *

WorkSafe claim number *

First name *

Last name *

Date of birth *

Client age

Please continue to complete this form

However, as your client is under 18, you must also follow your organisation's Child Safety Policies in relation to this matter.

Client’s family/guardian notified? *

YesNo

You must notify the client’s family or guardian as soon as possible to explain the serious incident that has occurred and the action being taken to meet the immediate needs of the client.

What actions have been taken and what follow-up actions will be taken for this child/young person? *

Does the client need additional support? *

YesNo

What additional support does the client need? *

Crisis Assessment and Treatment Teams - CATCentre Against Sexual Assault – CASADisability Services Commissioner – DSCNational Disability Abuse and Neglect HotlineVictorian Disability Worker Commission (VDWC) Police

Choose all that apply

Have these supports been provided?

YesNo

How have the immediate needs of the client been addressed? *

Please provide details of the type(s) of Restrictive Practice you intend to use and what least restrictive options you have already explored? *

Does the client have a paid family member as a support worker? *

YesNo

Restrictive practice details

Who in the organisation approves the intended use of restrictive practice? *

Does your organisation have an Authorised Program Officer (APO)? *

YesNo

APO name *

APO phone number *

APO email *

Incident details

Restrictive practice incident details

Date and time incident occurred *

Date and time incident identified *

Place where incident occurred *

Address where incident occurred *

Street address *

City *

State *

Postcode *

Incident type *

Please provide details about the type of incident *

Was there a witness or someone else involved? *

YesNo

Witness full name

Staff? *

YesNo

Role *

ParticipantWitnessVictim

Injured? *

YesNo

Medical professional required? *

YesNo

Describe the incident and the immediate response of staff *

Client’s recollection of the incident *

Who was the person that made the decision to use emergency restrictive practice? *

Has the Authorised Program Officer been advised of the emergency use of restrictive practice? *

YesNoNo APO

Supervisor's report

Has an internal investigation been completed or is one underway? *

YesNo

What actions have been taken and what follow-up actions will be taken in response to the incident? *

Other areas notified

Line manager/CEO informed? *

YesNoN/A

Police contacted? *

YesNoN/A

WorkSafe Victoria notified? *

YesNoN/A

Coroner contacted? *

YesNoN/A

By submitting this form you are agreeing all information provided is correct and you are authorised to submit this information

Personal and health information

TAC

The TAC will retain the information provided and may use or disclose it to make further inquiries or assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information. Without this information, the TAC may be unable to determine entitlements or assess whether treatment is reasonable and may not be able to approve further benefits and treatment. If you require further information about our privacy policy, please contact the TAC

Victorian Workcover Authority

Personal and health information collected by the Victorian WorkCover Authority (VWA) and its Agents on this form is used for the purpose of processing, assessing and managing claims under Victorian workers' compensation legislation to assist with a worker's rehabilitation and return to work and to assist the VWA and its Agents to better manage claims generally.

For the purposes of processing, assessing and managing a claim, the VWA and the Agent of the injured worker's employer may use and/or disclose personal and health information collected in this form or about the worker to each other and to the following types of organisations:

employees, contractors and agents of the VWA and its Agents;
employers of the injured worker;
solicitors, medical practitioners and other health service providers, private investigators, loss adjusters and other service providers acting on behalf of the VWA or the Agent in relation to the claim;
the Accident Compensation Conciliation Service and Medical Panels;
a court or tribunal in the course of criminal proceedings or any proceedings under any of the Acts which the VWA administers;
any other person, organisation or government agency authorised by the individual the information is about, or by law, to obtain the information.

An individual may request access to personal and health information about them collected by the VWA or an Agent by contacting the Agent. Personal and health information collected by the VWA is managed in accordance with the legislation, applicable privacy laws, and the VWA Privacy Policy.

The VWA Privacy Policy is available at the nearest the VWA office or at vwa.vic.gov.au.