Incident Report	
Client in Confidence
Information in this document is subject to the confidentiality provisions of the 
Children and Young People Act 2008 and the Health Records (Privacy and Access) Act 1997	
Incident Report #:	Date of Incident:	
Category 1 Reportable Incidents
Note: the recording of the category of the incident must be completed by the Unit Manager

 Death in custody
 Attempted suicide
 Serious injury
 Escape
 Serious assault 
 Major breach to detention place security
 Natural/man-made disaster 
 Serious staff misconduct

Note: All Category 1 incidents must be immediately notified to the Director. Category 2 incidents require notification to the Director following the completion of the full report within 5 working days wherever possible.	Category 2 Reportable Incidents
Note: the recording of the category of the incident must be completed by the Unit Manager

      Assault
      Serious health complaint
      Fight
      Threats against Youth Detention Officer or any
 other person
      Contagious disease
      Attempted escape
      Minor breach of security 
      Significant disturbance to the good order of a detention place 
      Self-harm
      Incident involving contraband (including weapons, tools of escape, and illicit drugs)
      Motor vehicle accident 
      Incident involving visitor/s to a detention place 
      Possession of a prohibited thing at a detention place by a Youth Detention Officer or staff member 
      Any other event that in the opinion of the Manager should be reported.	
Response	
What operational responses took place to control the incident?	Referrals 	

 Use of Force
 Attend Hospital
 Behaviour Management Plan
 Special Management Directions
 Segregation Direction
 Direction for a Body Search
 Total Lockdown
 Evacuation	
 AFP                 Job No#                                      .             
 FMH
 YJCM/CPS
 Family/Significant Other
 Health – Date of Referral ____/____/____
 Referral to Supervisor for Counseling
 Refer for Investigation through Shared Services

Incident Report	Incident Report #	
Incident Details
All required reports are the responsibility of the youth detention officer and are to be fully completed before youth detention officers complete their shift, unless otherwise approved by the manager.
Staff should use objective language. Reports shall contain direct evidence of what occurred in any incident (I saw, I heard, I smelled, he/she said, I said), reports should not contain assumptions or opinions. Reports must be factual as they may be used in court as direct evidence of fact.	
Date of Incident		Time of Incident
(if appropriate start and end time of the incident)	   	
Location of Incident
(include as much detail as possible)		
Describe the Incident		
What led up to the incident?	 	
What action was taken?	    	
Describe Use Of Force technique if used	

Person/s Involved	1. First Name: 
Surname:  
Position:  	2.First Name:  
Surname:  
Position:  	3. First Name: 
Surname: 
Position:  	
Witness/s to the incident	1.First Name: 
Surname:  
Position:  	2.First Name:
Surname:
Position:	3.First Name:
Surname:
Position:	
Was physical intervention required?
–including use of instruments of restraint	Describe:  

Was the safe room used?	Describe:  

Injury to person/s	Describe:  
	
Was medical assistance requested?		Was the AFP contacted?
If No, for a Death in Custody, the Coroner?	 Yes     No
Date: ____/____/____	
For a Death in Custody was the Body Receipt Register completed?	 Yes      No                                   Date: ____/____/____	
Director notified of the incident (as soon as practicable) 	Date: ____/____/____	Time: ___________ am/pm	
ACT Insurance Authority Incident form completed (within 5 working days for Cat 1)	 Yes      No                                   Date: ____/____/____	
Person/s with parental responsibility notified	Date: ____/____/____	Time: ___________ am/pm	
Were relevant audio and video reports of the incident downloaded?	Audio  No
            Yes	Video  No
            Yes 	
Report completed by:	Name:  
Position: 	Signature: ______________________
Date: 	
Role in Incident		
Additional Record-Keeping
 Search/Use of Force Record #______		
 Register of Segregation Direction #______
 ACTIA Report form #_____
Attachments: 
 Witness Report # of Reports: 		 Person/s Involved Report # of Reports: 
 Unit Manager’s Report 			 Operation Manager’s Report
 Senior Manager’s Report			 Attending Medical Practitioner’s Report
Approved:	Name:	Position:	Date: ___/___/_____	

Witness Report 		Number:					Attachment:    

All required reports are the responsibility of the youth detention officer and are to be fully completed before youth detention officers complete their shift, unless otherwise approved by the manager.

All Reports should have objective language. Reports shall contain direct evidence of what occurred in any incident (I saw, I heard, I smelled, he/she said, I said), reports should not contain assumptions or opinions. Reports must be factual as they may be used in court as direct evidence of fact.  
When the incident happened	

	
Where it happened	

	
What happened?	

	
Who was involved?	

	
Report completed by	Name: _________________________
 Bimberi Youth Justice Centre Staff
 Visitor                Young Person
 Other ____________________	Signature: ______________________
Date: ____/____/____	
Role in Incident		

Person/s Involved Report	   Number:					Attachment:  

All required reports are the responsibility of the youth detention officers and are to be fully completed before youth detention officers complete their shift, unless otherwise approved by the manager.

All Reports should have objective language. Reports shall contain direct evidence of what occurred in any incident (I saw, I heard, I smelled, he/she said, I said), reports should not contain assumptions or opinion. Reports must be factual as they may be used in court as direct evidence of fact.  
When the incident happened	

	
Where it happened	

	
What happened?	

	
Who was involved?	

	
Report completed by	Name: _________________________
 Bimberi Youth Justice Centre Staff
 Visitor                Young Person
 Other ____________________	Signature: ______________________
Date: ____/____/____	
Role in Incident		

Management Reports 						                     Attachment: 

Unit Manager’s Report on the Incident	
Comments on staff response to the incident—was the action taken appropriate and effective? 

Further action:

 QA cover sheet
 Brief Summary
 Investigate the incident
 Identify management strategies
 Follow up the incident
 What has been done to rectify and improve practice

Unit Manager’s signature:							Date: ____/____/____

Review by Senior Manager and Operations Manager	
Comments on staff response to the incident—was the action taken appropriate and effective?

Other comments:

Senior Manager’s Signature:							Date: ____/____/____

Operations Manager’s Signature:						Date: ____/____/____

Director’s comments on the Incident and response	

Director’s Signature:							Date: ____/____/____

Record of Medical Referral 							Attachment:

Attending Medical Practitioner’s Comments on the Incident	

Name: _____________________	 	Qualification: ___________________
Signature: _____________________	Date: ____/____/____