7.2.1 QPCYWA Accident/Incident Report & Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Answer these questions before continuing with this form.

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

  Yes

  No

• Record Info in Day Log ONLY.

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

  Yes

  No

• Complete sections A, B, C

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

  Yes

  No

• Complete sections A, B

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

  Yes

  No

• 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

  Date

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

• Family/Surname

• Given Name

• Gender

  Select Male Female

  • Male
  • Female

• Date of Birth

  Date
• Address
  Address

• Phone Number (Home)

• Phone Number (Mobile)

• Position

  Select Staff Volunteer Childcare Visitor Other

  • Staff
  • Volunteer
  • Childcare
  • Visitor
  • Other

• Please Specify

• PCYC Club Member #

Parent/Guardian Details (if person is under 18)

• Family/Surname

• Given Name

• Relationship to Child

• Signature

  Sign

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

  Select Staff Volunteer Childcare Visitor Other

  • Staff
  • Volunteer
  • Childcare
  • Visitor
  • Other

• 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

  Media

• Type of Activity (tick any box that applies)

  Select Basketball SAC Dance Squash Gymnastics/Trampoline Weights SYLP Martial Arts Staff Work Netball Boxing Other

  • Basketball
  • SAC
  • Dance
  • Squash
  • Gymnastics/Trampoline
  • Weights
  • SYLP
  • Martial Arts
  • Staff Work
  • Netball
  • Boxing
  • Other

• Please Specify

Staff Use Only

• Please tick as many boxes as apply

  Select Safety Problem Vehicle Incident Near Miss Act of Violence Journey Incident Work caused illness or disease Work injury Non-Work injury Serious Bodily Event Dangerous Event Serious Electrical Event Dangerous Electrical Event

  • Safety Problem
  • Vehicle Incident
  • Near Miss
  • Act of Violence
  • Journey Incident
  • Work caused illness or disease
  • Work injury
  • Non-Work injury
  • Serious Bodily Event
  • Dangerous Event
  • Serious Electrical Event
  • Dangerous Electrical Event

• 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?

  Yes

  No

• 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

  Select None First Aid Doctor Hospital Casualty Ambulance Paramedic Hospital Stay Other

  • None
  • First Aid
  • Doctor
  • Hospital Casualty
  • Ambulance Paramedic
  • Hospital Stay
  • Other

• Please Specify

• Date Injury Reported

  Date

• Name of person to whom it was reported:

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

• Where did the injury/accident occur?

  Select At PCYC At School Age Care Traffic accident while working At work on a break Journey to or from work Other

  • At PCYC
  • At School Age Care
  • Traffic accident while working
  • At work on a break
  • Journey to or from work
  • Other

• 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

  Select Staff Volunteer Childcare Visitor Other

  • Staff
  • Volunteer
  • Childcare
  • Visitor
  • Other

• 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

  Media

• Equipment Involved (if any + details)

• Substances Involved (if any + details)

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

• Signature of Investigator

  Sign

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

  Yes

  No

• Is the Risk Assessment available for for evaluation?

  Yes

  No

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

  Yes

  No

• 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?

  Date

• What date were the short term actions completed?

  Date

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?

  Date

• What date were long term actions completed?

  Date

• 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

  Sign

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

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

  Yes

  No

• Complete 7.2.1 pages 1-4 before continuing.

• School Age Care Name/Location

• Has ECEC been notified of incident?

  Yes

  No

• Person making notification

• Date and time of notification

  Date

• 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:

  Phone

  Email

  Other

• Please Specify

• Name of operations officer

• Time and date of notification

  Date

• Person making notification

• Name of parent/ guardian who was notified

• Relationship to child

• Time and Date of notification

  Date

• Person making notification

Emergency and Action Notification Details

• First Aid Administered?

  Yes

  No

• First aid administered by

• Expiry date of first aid certificate

• Briefly describe first aid administered

• Administration of medication?

  Yes

  No

• Complete medication form

• Details of medication

• Time medication administered

  Date

• Doctor notified?

  Yes

  No

• Name/phone of doctor

• Ambulance notified?

  Yes

  No

• Time notified

  Date

• Other person notified?

  Yes

  No

• Name/phone of person

• Add drawing

  Drawing