CVM Incident Report

• Do not enter text or alter the Incident Report Number Box, it will autogenerate the Incident Report Number.

• Incident Report Number

• Site

  Select

• Date & Time of Incident

  Date

• If selecting any Major Category or a Child Safety Incident, please contact your manager immediately. Your site manager will contact the relevant Site Support Person as required.

• INCIDENT CATEGORIES:
  
  Biological Hazard: Incidents relating to Code Browns, Infectious Clean-ups, or Sharps Found.
  
  Chemical Hazard: Incidents involving Chemical Spills or Chemical related Injuries.
  
  Child Safety: Incidents involving negligence of a child, sexual, physical or verbal abuse of a child.
  
  Confrontation: Incident involving people arguing, abusing or fighting.
  
  First Aid Treatment (Minor): Incidents with minimal damage, not requiring a follow up by a medical professional.
  
  First Aid Treatment (Major): Incidents where someone requires medical assistance, wither after the event, or by calling an Ambulance that is not life-threatening.
  
  Major Incident (Drowning): Incident that requires an unconscious patient to be removed from water and CPR commenced.
  
  Major Incident (Medical): Incident where someone requires immediate medical attention and is potentially life-threatening.
  
  Major Incident (Non-Medical): Incidents that are major but not medically related such as a evacuation, fire, bomb threat, or armed assault.
  
  Security Event: Incidents that involve non-life threatening theft or breaking and entering.
  
  Water Rescue: Incidents that involve removing a conscious swimmer from the water or any instance where lifeguard intervention is required to a swimmer to prevent injury or drowning.

• Incident Type

  Select Biological Hazard Chemical Hazard Child Safety Confrontation First Aid Treatment (Minor) First Aid Treatment (Major) Major Incident (Drowning) Major Incident (Medical) Major Incident (Non-Medical) Security Event Water Rescue

  • Biological Hazard
  • Chemical Hazard
  • Child Safety
  • Confrontation
  • First Aid Treatment (Minor)
  • First Aid Treatment (Major)
  • Major Incident (Drowning)
  • Major Incident (Medical)
  • Major Incident (Non-Medical)
  • Security Event
  • Water Rescue

• Emergency Services Involved

  Select No Emergency Service Ambulance Police Fire Department

  • No Emergency Service
  • Ambulance
  • Police
  • Fire Department

• Was the Person Involved an Employee or Patron

  Select Employee Patron No Person Involved

  • Employee
  • Patron
  • No Person Involved

• Person Completing this Report

  Sign

Person Involved in Incident

• Name

• Date of Birth

• Gender

• Address

• Phone

• Guardian's Name (If Applicable)

• Guardian's Mobile (If Applicable)

Site of Incident

• Area of Incident

  Select Car Park Reception Office Staff Room Health Club Group Fitness Room Outdoor Areas Playzone Male Bathrooms Female Bathrooms PWD Bathrooms Plant Room Chemical Storage Room Cleaning Storage Room 50m Pool 25m Pool 12m Pool Program Pool Splash Pool Outdoor Pool Concourse Indoor Pool Concourse Water Park (Splashdown) Water Park (Shotguns) Water Park (Lagoon) Water Park (Lilly Pads) Water Park (Kid's Slides) Other

  • Car Park
  • Reception
  • Office
  • Staff Room
  • Health Club
  • Group Fitness Room
  • Outdoor Areas
  • Playzone
  • Male Bathrooms
  • Female Bathrooms
  • PWD Bathrooms
  • Plant Room
  • Chemical Storage Room
  • Cleaning Storage Room
  • 50m Pool
  • 25m Pool
  • 12m Pool
  • Program Pool
  • Splash Pool
  • Outdoor Pool Concourse
  • Indoor Pool Concourse
  • Water Park (Splashdown)
  • Water Park (Shotguns)
  • Water Park (Lagoon)
  • Water Park (Lilly Pads)
  • Water Park (Kid's Slides)
  • Other

• Specific Location of Incident

Incident Details

• Please write a detailed description of the event with factual information only. Capture information so someone reading would be able to have full context.

• Description of Incident

(Optional) Witness Details

• Name

• Phone

• Address

• Witness Statement

(If Applicable) First Aid Report

• Area of Injury/Incident on Person

  Select Head Eye Nose Mouth Neck Chest Back Shoulders Arm Finger Upper Leg Lower Leg Foot Toe Whole Body Other (Please List in Notes) N/A

  • Head
  • Eye
  • Nose
  • Mouth
  • Neck
  • Chest
  • Back
  • Shoulders
  • Arm
  • Finger
  • Upper Leg
  • Lower Leg
  • Foot
  • Toe
  • Whole Body
  • Other (Please List in Notes)
  • N/A

• Type of Injury

  Select Allergic Reaction Asthma Break Bruise / Blunt Trauma Burn Chemical Burn Cut / Laceration Dismemberment Drowning Faint / Blackout Heart Attack Seizure Scratch / Graze Strain / Sprain N/A Other (Please List in Notes)

  • Allergic Reaction
  • Asthma
  • Break
  • Bruise / Blunt Trauma
  • Burn
  • Chemical Burn
  • Cut / Laceration
  • Dismemberment
  • Drowning
  • Faint / Blackout
  • Heart Attack
  • Seizure
  • Scratch / Graze
  • Strain / Sprain
  • N/A
  • Other (Please List in Notes)

• Describe Treatment Given & For How Long

• Was Oxygen / Defibrillation Required

  Select Oxygen Resuscitation Oxygen Therapy Defibrillation No Equipment Used

  • Oxygen Resuscitation
  • Oxygen Therapy
  • Defibrillation
  • No Equipment Used

• Was further medical treatment advised post event?

  Yes

  No

• What further treatment was advised & why?

(Add if Required) Ambulance Involvement

• Time Called

  Date

• Time Arrived

  Date

• Any additional notes given by Paramedics

(Add if Required) Police Involvement

• Time Called

  Date

• Time Arrived

  Date

• Police Investigation Number

• Responding Officer / Investigator

(Add if Required) Fire Department Involvement

• Time Called

  Date

• Time Arrived

  Date

• Time allowed back on site (If Applicable)

  Date

Follow Up Requirements

• If incident requires further investigation and follow up, Please select Yes to the questions below, which will notify the site manager. Please also contract Manager directly. Site Managers should contact required persons for follow up within 48 hours.

• Is further investigation & follow up required by the Site Manager?

  Yes

  No

• If an incident involves learn to swim programming please select yet to notify Learn to Swim General Manager.

• Is further investigation & follow up required due to Learn to Swim related Incident?

  Yes

  No

• If an incident involves learn to swim programming please select yet to notify Squad General Manager.

• Is further investigation & follow up required due to Squad related Incident?

  Yes

  No
Incident Investigation (To Be Completed if Required)

• Use the optional items below to gather data to help determine the primary and root cause of the incident, and provide a summary and conclusion to the investigation. If control items are required, add them in the next section, titled: Control Actions.

• Information Gathered

  Select Witness Statements Gathered CCTV Reviewed | Gathered Procedure | Policy Reviewed | Gathered Relevant Operational Documents Gathered Qualifications Reviewed | Gathered Induction | Training Reviewed | Gathered Child Safety Only: Employee Stood Down

  • Witness Statements Gathered
  • CCTV Reviewed | Gathered
  • Procedure | Policy Reviewed | Gathered
  • Relevant Operational Documents Gathered
  • Qualifications Reviewed | Gathered
  • Induction | Training Reviewed | Gathered
  • Child Safety Only: Employee Stood Down

• Environmental Factors Contributed

  Yes

  No

• Environmental Factors Contributing to the Incident

  Select Noise Lighting Vibration Damaged/Unstable Ground Layout/Design Dust/Fumes Slip/Trip Hazard Other

  • Noise
  • Lighting
  • Vibration
  • Damaged/Unstable Ground
  • Layout/Design
  • Dust/Fumes
  • Slip/Trip Hazard
  • Other

• Elaborate Reasoning for Response Selection

• Equipment/Material Factors Contributed

  Yes

  No

• Equipment/Material Factors Contributing to the Incident

  Select Wrong Equipment Used Inadequate Maintenance Inadequate Guarding Equipment Failure Material/Equipment too Heavy/Awkward Inadequate Training Provided No PPE / Safety Equipment Used

  • Wrong Equipment Used
  • Inadequate Maintenance
  • Inadequate Guarding
  • Equipment Failure
  • Material/Equipment too Heavy/Awkward
  • Inadequate Training Provided
  • No PPE / Safety Equipment Used

• Elaborate Reasoning for Response Selection

• Work System Factors Contributed

  Yes

  No

• Work System Factors Contributing to the Incident

  Select Hazard Not Identified No/Inadequate Safe Work Procedures Hazard Not Reported No / Inadequate Risk Assessment Conducted No / Inadequate Controls Implemented Inadequate Training / Supervision

  • Hazard Not Identified
  • No/Inadequate Safe Work Procedures
  • Hazard Not Reported
  • No / Inadequate Risk Assessment Conducted
  • No / Inadequate Controls Implemented
  • Inadequate Training / Supervision

• Elaborate Reasoning for Response Selection

• People Factors Contributed

  Yes

  No

• People Factors Contributing to the Incident

  Select Procedure Not Followed / No Procedure Exists Fatigue Change of Routine Lack of Communication Drugs / Alcohol Time / Production Pressures Distraction / Personal Issues / Stress Unusual Working Conditions Pre-Existing Medical Conditions

  • Procedure Not Followed / No Procedure Exists
  • Fatigue
  • Change of Routine
  • Lack of Communication
  • Drugs / Alcohol
  • Time / Production Pressures
  • Distraction / Personal Issues / Stress
  • Unusual Working Conditions
  • Pre-Existing Medical Conditions

• Elaborate Reasoning for Response Selection

• Determine the primary cause/s of the incident, that is, those which if they hadn’t occurred then the incident wouldn’t have occurred. Ask yourself “Would the incident have happened if….?”

• What is the Primary Cause of the Incident (If Applicable)

• One technique for identifying the root cause is the ‘Five Whys’. This technique involves asking yourself ‘Why did this happen?’ and continuing to ask ‘Why’ for each response until you reach a conclusion that does not generate another ‘why’ and the underlying cause becomes apparent.

• What is the Root Cause of the Incident (If Applicable)

• Investigation Summary

• Investigation Conclusion

• Person Completing this Investigation

  Sign
Control Actions

• Control or Action Required

• Has Control Been Implemented

  No

  Yes

• Date to be Completed or Reviewed

  Date

• Person/Department Responsible for Control