Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Answer these questions before continuing with this form.

  • 1. Did the accident/incident only require a Band Aid or Ice?

  • Record Info in Day Log ONLY.

  • 2. Did the accident/incident happen to a child in School Age Care?

  • Complete sections A, B, C

  • 3. Did the accident/injury involve a head injury? (Even if ice given)

  • Complete sections A, B

  • 4. Did any other accident/incident happen to any person?

  • Complete sections A, B

  • Investigation Section B, must be completed by supervisor within 24 hours and submitted to admin@pcyc.org.au

SECTION A - Accident/Incident Report.

  • PCYC Branch

  • Location

  • Date and Time of Incident

Details of the person injured or involved in the accident/incident.

  • Family/Surname

  • Given Name

  • Gender

  • Date of Birth

  • Address
  • Phone Number (Home)

  • Phone Number (Mobile)

  • Position

  • Please Specify

  • PCYC Club Member #

Parent/Guardian Details (if person is under 18)

  • Family/Surname

  • Given Name

  • Relationship to Child

  • Signature

Name and contact details of person completing form if not the same as above

  • Family/Surname

  • Given Name

  • Phone Number (Home)

  • Phone Number (Mobile)

  • Position

  • Please Specify

Witness names and contact details

  • Witness 1

  • Family/Surname

  • Given Name

  • Phone Number (Mobile)

  • Witness 2

  • Family/Surname

  • Given Name

  • Phone Number (Mobile)

Incident/Event Details

  • Please Describe

  • Tap here to add photo

  • Type of Activity (tick any box that applies)

  • Please Specify

Staff Use Only

  • Please tick as many boxes as apply

  • If the incident is a Serious Bodily Event, Dangerous Event, Serious Electrical Event or Dangerous Electrical Event, it MUST be reported to Workplace Health and Safety Queensland immediately via phone or online.
    Workplace Health and Safety QLD (Phone 1300 369 915).
    If you report the incident to Workplace Health and Safety QLD, please also advise the State Health & Safety Advisor immediately - 0414 421 998.

  • Was this accident/incident reported to Workplace Health and Safety Qld?

  • If the incident is a Serious Bodily Event, Dangerous Event, Serious Electrical Event or Dangerous Electrical Event, it MUST be reported to Workplace Health and Safety Queensland immediately via phone or online.
    Workplace Health and Safety QLD (Phone 1300 369 915).

Mechanism of Injury

  • How did the injury/illness happen - eg: slip/ trip/ fall, hit by a person, equipment, heat or cold, electricity, vehicle accident, substances, etc.

  • Initial Treatment

  • Please Specify

  • Date Injury Reported

  • Name of person to whom it was reported:

  • Phone no. (mobile) of person to whom it was reported:

  • Where did the injury/accident occur?

  • Please Specify

SECTION B - Accident/Incident Investigation

  • Staff use only - accident/incident investigation - fill in section B of this form.
    Investigation much be conducted by Supervisor or Health & Safety Rep. within 24 hours.
    This section is mandatory for all incidents.

Investigating Person

  • Family/Surname

  • Given Name

  • Position/title (Manager, Supervisor, etc)

  • Phone Number (Work)

  • Phone Number (Mobile)

  • Position

  • Please Specify

Describe the incident/ problem or event - This section is mandatory for all incidents.

  • State the facts only, established after rid investigation. Do not state opinions.

  • Tap here to add photo

  • Equipment Involved (if any + details)

  • Substances Involved (if any + details)

  • Environment (indoor, outdoor, wet, dry etc)

  • Signature of Investigator

  • Is there an existing Risk Assessment document for the activity?

  • Is the Risk Assessment available for for evaluation?

  • Attach a copy to this report for reference. Copy attached?

  • If an incident has occurred, supervisors MUST review any/all Risk Assessment documents associated with the activity for currency and adequacy as part of the investigation.
    If there are any photographs or video of the incident, this evidence must be retained by the investigator.

Short term corrective measures taken (controls to minimise risk and prevent reoccurrence)

  • Describe the short term actions that were taken or that are recomended

  • What date were the short term actions taken?

  • What date were the short term actions completed?

Long term corrective measures taken (controls to minimise risk and prevent reoccurrence)

  • Describe the long term actions that were taken or that are recommended

  • Start date: when will long term actions be carried out?

  • What date were long term actions completed?

  • Who is the person responsible for ensuring actions are/were taken?

  • Contact details of Peterson responsible for ensuring actions are/were taken (email, phone)

Acknowledgement - mandatory for all incidents

  • Name of manager/supervisor of injured or of the work area involved confirming receipt of report

  • Position/Title

  • Phone number (work)

  • Phone number (mobile)

  • Signature

SECTION C - School Age Care ONLY. Staff use only.

  • Have pages 1-4 of form 7.2.1 Incident Report and Investigation been completed?

  • Complete 7.2.1 pages 1-4 before continuing.

  • School Age Care Name/Location

  • Has ECEC been notified of incident?

  • Person making notification

  • Date and time of notification

  • Why was ECEC not notified?

  • Serious incidents, injury and illness must be reported via phone/email within 24 hours of incident occurring.

  • Notification was made to the operation officer:

  • Please Specify

  • Name of operations officer

  • Time and date of notification

  • Person making notification

  • Name of parent/ guardian who was notified

  • Relationship to child

  • Time and Date of notification

  • Person making notification

Emergency and Action Notification Details

  • First Aid Administered?

  • First aid administered by

  • Expiry date of first aid certificate

  • Briefly describe first aid administered

  • Administration of medication?

  • Complete medication form

  • Details of medication

  • Time medication administered

  • Doctor notified?

  • Name/phone of doctor

  • Ambulance notified?

  • Time notified

  • Other person notified?

  • Name/phone of person

  • Add drawing

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.