Please use this form in conjunction with the ‘Training organisation adverse event and critical incident reporting guideline’.
Updates on already reported adverse event or critical incidents must be detailed here, on the original reporting form.

Incident update

Initial RACGP notification date of incident

Details of report progress updates

Training organisation incident details

Name of training organisation

Name and position of person completing incident report

Incident reported to training organisation by:

Medical educator
Supervisor
GP in training (GPiT)
Practice manager
Other (please specify)

Date of incident

Time of incident (if applicable)

Date training organisation became aware of incident

Incident discussed with relevant state censor
Y	N

Date training organisation notified the RACGP

Is this incident related to an alternative model of supervision?
Y	N

Model name

Details of incident/event

Location where the incident occurred (eg practice name, hospital, community location)

Parties involved:

GPiT – Australian General Practice Training (AGPT)
GPiT – Practice Experience Program (PEP)
Supervisor
Practice manager
Patient
Medical educator
Other (please specify)

Name of GPiT (if applicable)

AHPRA number of GPiT (if applicable)

Name of supervisor (if applicable)

AHPRA number of supervisor (if applicable)

Describe the critical incident/adverse event, including any injury or illness incurred. Detail any actual harm and risks that may persist.

Details (name and position) of any witnesses.

Describe the actions taken to date to manage the incident for all parties involved. Please include details of any responsible committee (name and date) with whom the incident was discussed and actions planned.

Describe the planned actions to manage the incident for all parties involved going forward.

Describe any broader risk assessment activities undertaken, including any outcomes and/or any monitoring implemented. Please include a timeframe of when the RACGP can expect an update.

Describe any changes made or being considered because of these events/circumstances. Please provide comments on any ongoing monitoring that may include reporting to the RACGP on progress.

Anticipated final resolution date (if applicable)

Training organisation, CEO or lead medical educator name

Signature

Date

Please return this completed report and any attachments to criticalincidents@racgp.org.au

If using the word document please PDF before emailing it to the RACGP.