Participant Critical Incident Form

redacted: s47F - personal privacy

FOI 24/25-1367 - DISCLOSURE LOG

DOCUMENT 9

redacted: s47E(d) - certain operations of agencies

The purpose of this form is for NDIA, NCC and Partner staff receiving allegations of a participant critical incident (PCI) to record key information. PCIs are allegations of serious incidents which result in harm to a NDIS participant or tier 2 customer and may be reported by a participant, carer, nominee, NDIA, NCC, Partner staff or any other relevant party.

NDIA, NCC staff and Partner staff must ensure the participant and others are safe when first being notified of a PCI. If the participant or another person is in immediate danger or harm or requires urgent assistance, contact emergency services immediately.

Participant: A person becomes a participant in NDIS once the CEO determines that they satisfy the access criteria. Source: NDIS Act 2013 s28.

Tier 2 Customer: A Tier 2 customer is a person with a disability that is engaged with a Partner Organisation and the primary form of support provided is information sharing, referral services, or access pathway support.

Instructions

IMPORTANT: Do not attach this document to CRM or PACE. The form and relevant documents and emails should be stored in accordance with Agency record keeping requirements.

For a Participant or Tier 2 Customer:

If a critical incident has been reported for a participant or tier 2 customer, please progress by creating a Participant Critical Incident case in PACE via this link: New Case | Salesforce (mcas.ms). This form is only for use when PACE cannot be accessed.

If required, please email the completed form to redacted: s47E(d) - certain operations of agencies@ndis.gov.au

What happens next:

Participant Incident staff will contact you to advise of any next steps if applicable.

Page 56 of 498

FOI 24/25-1367 - DISCLOSURE LOG

Participant Critical Incident Information

TRIGGER CONTENT WARNING	Does this report contain triggering content?
(does the content/details of this Participant Critical Incident form have the potential to cause upset or distress due to sensitive information)	[Choose an item]
	If yes please select
	[Choose an item]
	[Choose an item]
If OTHER please specify

1. Incident Summary

IMPORTANT: ALL FIELDS MUST BE COMPLETED

Please use this section to record key information about the critical incident.

Incident Summary Details	Details
Person impacted by the alleged incident	Provide name
NDIS Number	Provide NDIS number
Participant or Tier 2 Customer	[Choose an item]
Contact details Provide contact details for person or their Nominee/Representative	Contact phone number: Email: Select State or Territory where Participant resides: [Choose an item]
Date incident reported to NDIA (date that NDIA was informed)	Click or tap to enter a date.
Date and time alleged incident occurred	if unknown, state reason why this is unknown Click or tap to enter a date.
Person/ provider reporting the incident to NDIA and their relationship to the participant	Provide reporters name and relationship to the person OR advise if to remain anonymous Insert reporters name, relationship or state Anonymous here
Contact details of person or provider reporting the incident to the NDIA	Provide phone number, email address or other provided contact details of the person or provider reporting the incident OR advise if to remain anonymous Insert reporters contact details here

Page 57 of 498

FOI 24/25-1367 - DISCLOSURE LOG

Is the allegation in relation to a provision of services and supports?	Please note the NDIS Commission cannot investigate an incident if the Provider details are missing
	[Choose an item]
IF YES: NDIA Provider name and registration number must be supplied	Insert Provider name Insert Provider registration number, or advise if unregistered
Method of Contact (how was this reported to NDIA)	[Choose an item] (if other please specify details)

2. Incident Category

Incident Category	Details
Primary Category	[Choose an item]
	Please specify type of incident if further explanation is required eg. Financial abuse or Environmental Restraint etc. If the incident does not fit into any of the specified categories, please contact `redacted: s47E(d) - certain operations of agencies`@ndis.gov.au to discuss if a PCI needs to be lodged Insert further explanation of the category here

3. Incident Details

Incident Details	Details
Incident location/address	Insert Incident location/address
Location type (if other please specify details)	[Choose an item]
Brief description of the incident/allegation	Use this area to record all details and conversations regarding the incident. Please note whilst reference can be made to documents and interactions on the CRM or PACE business systems, a summary is still required to be entered into this field to ensure timely triage. If incident regards Unauthorised Restrictive Practice (URP), please detail what URP is being used and further information to support the allegations. For example, if

Page 58 of 498

FOI 24/25-1367 - DISCLOSURE LOG

Incident Details	Details
	Chemical Restraint - please include dosage, medicines used, whether there is a Positive Behaviour Support Plan, etc. Insert brief description here
What Immediate actions have been taken before advising as a Participant Critical incident?	☐ Police Attended ☐ Ambulance Attended ☐ Emergency Services Called ( 000 )
Were emergency services contacted? Please select all that apply.	☐ Participant/Tier 2 Customer Transferred to Hospital ☐ Child Protection Notified ☐ Other (please provide details)
If so, is there any update or outcome?	If a report has been made to the relevant authorities please include the reference number here. Please provide brief, factual representations of conversations and actions with the participant/tier 2 customer, authorised representatives, providers, your line manager and any other activity to date, regarding the incident. Insert further explanation here
Is the Participant or Tier 2 Customer safe in their current accommodation? If NO, provide details	[Choose an item] If NO – provide details including the nature of the risk and likelihood of further incidents occurring.
What actions have taken place to ensure Participant or Tier 2 Customer has sufficient supports in place to prevent further incidents?	What actions have the business area undertaken to ensure the person’s safety and sufficient supports are in place? Is there a plan reassessment required? Insert further explanation here

Page 59 of 498

FOI 24/25-1367 - DISCLOSURE LOG

Version Control

Version	Amended by	Brief Description of Change	Status	Date
2.0	TEM907	Updates to support inclusion of Tier 2 Customers in the critical incident reporting process – changes endorsed by EL2 PEE824	APPROVED	2025-02-18

Page 60 of 498