Audit

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
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.