Design Tech Incident Report

• Document No.

• Incident Location

  Outside D-BLOCK

  D1

  D2

  D3

• Conducted on

  Date

• Prepared by

• Signature

  Sign

1. INJURED PESON'S DETAILS

• INJURED PERSON.

  Staff Member

  School student

  Other person

• Full Name:

• Association with school:

  Select Staff Student Parent Public Visitor Volunteer Other

  • Staff
  • Student
  • Parent
  • Public
  • Visitor
  • Volunteer
  • Other

• Student ID (if known)

• Address:

• Suburb:

• Post Code:

• Phone:

• Emergency Contact Name (if known)

• Emergency Contact Number (if known)

• Why on school property:

2. REPORTING PERSON OR FIRST AID ATTENDANT

• Whether its a staff or other person (if not staff please provide address and phone number )

  Staff Member

  Other Person

• Full Name:

• Department:

• Address (only if NOT staff)

• Phone Number (only if NOT staff)

3. WHAT HAPPENED ?

• Detailed description of incident ( consider the activity, what happened and why)

• Provide more details if necessary:

• Add/take picture of incident for record

  Media

4. INCIDENT INFORMATION

• ACTIVITY - What was the activity at the time of the incident ?

  Select Admin General Assisting student Chemicals/poisons Computer Work Curriculum Prac CurriculumTheory Equipment Usage First Aid Lesson Prep/ Clean up Manual handling Maintenance Meeting Movement around school Non-school activity Restraining Student School Activity Unauthorized Activity Work General Other: (e.g bullying)

  • Admin General
  • Assisting student
  • Chemicals/poisons
  • Computer Work
  • Curriculum Prac
  • CurriculumTheory
  • Equipment Usage
  • First Aid
  • Lesson Prep/ Clean up
  • Manual handling
  • Maintenance
  • Meeting
  • Movement around school
  • Non-school activity
  • Restraining Student
  • School Activity
  • Unauthorized Activity
  • Work General
  • Other: (e.g bullying)

• CAUSE - What caused he injury?

  Select Caught in/between Contact with Exposure to Object falling/flying Person falling Lifting/Handling Repetitive movement Running/jumping Stepping on /in Walking Struck by / or against Other

  • Caught in/between
  • Contact with
  • Exposure to
  • Object falling/flying
  • Person falling
  • Lifting/Handling
  • Repetitive movement
  • Running/jumping
  • Stepping on /in
  • Walking
  • Struck by / or against
  • Other

• SEVERITY

  Select Minor (first aid/no time lost) Moderate (needs medical care) Serious (>4days away/perm injury/damage) Fatal

  • Minor (first aid/no time lost)
  • Moderate (needs medical care)
  • Serious (>4days away/perm injury/damage)
  • Fatal

• TREATMENT REQUIRED

  Select Nil First Aid (at incident location) First Aid (Sick Bay) First Aid (Ambulance Paramedic) Doctor/out patients Hospitalisation (overnight stay or longer)

  • Nil
  • First Aid (at incident location)
  • First Aid (Sick Bay)
  • First Aid (Ambulance Paramedic)
  • Doctor/out patients
  • Hospitalisation (overnight stay or longer)

• If first aid - what first aid was provided?

• If hospitalised - What is the name of the hospital ?

5. INJURY / ILLNESS DETAILS

• Injury / Illness

  Select Ache/Pain Amputation Bite/Sting Bruise/crush Bump/Knock Burn/Scald Concussion Cumulative Cut/laceration Dislocation Fracture Headache Hearing Loss Infection/Disease Irritation/Allergy Nausea Poisoning Respiratory Sprain/strain Stress reaction Unconscious Unspecified Other

  • Ache/Pain
  • Amputation
  • Bite/Sting
  • Bruise/crush
  • Bump/Knock
  • Burn/Scald
  • Concussion
  • Cumulative
  • Cut/laceration
  • Dislocation
  • Fracture
  • Headache
  • Hearing Loss
  • Infection/Disease
  • Irritation/Allergy
  • Nausea
  • Poisoning
  • Respiratory
  • Sprain/strain
  • Stress reaction
  • Unconscious
  • Unspecified
  • Other

• Location on the Body

  Select Ankle(s) Arm(s) Back lower Back upper Chest Ear(s) Elbow(s) Eye(s) Face Finger(s) Foot/feet Groin Head Hand(s) Hip(s) Internal Knee(s) Leg(s) Mouth Neck Nose Respiratory system Shoulder(s) Skin Stomach Stress related Toe(s) Tooth/teeth Wrist(s) Other:

  • Ankle(s)
  • Arm(s)
  • Back lower
  • Back upper
  • Chest
  • Ear(s)
  • Elbow(s)
  • Eye(s)
  • Face
  • Finger(s)
  • Foot/feet
  • Groin
  • Head
  • Hand(s)
  • Hip(s)
  • Internal
  • Knee(s)
  • Leg(s)
  • Mouth
  • Neck
  • Nose
  • Respiratory system
  • Shoulder(s)
  • Skin
  • Stomach
  • Stress related
  • Toe(s)
  • Tooth/teeth
  • Wrist(s)
  • Other:

• Sign - Reporting person or First Aid attendant

  Sign

• Sign - Injured Person

  Sign

6. EMERGENCY CONTACT DETAILS

• Has the injured persons emergency contact been notified? If not, why?

  Yes

  No

  N/A

7. CAUSE OF ILLNESS/INJURY

• Was the injury/Illness caused by a confrontation or aggressive act?

  Yes

  No

  N/A

• If aggressor?

  Select Parent staff volunteer primary student secondary student Visitor other

  • Parent
  • staff
  • volunteer
  • primary student
  • secondary student
  • Visitor
  • other

• Type of confrontation?

8. HAZARD INFORMATION/MANDATORY (if necessary seek assistance from school WHSO to determine the hazard)

• What was the primary hazard that caused the incident?

• Contributing Hazard Category (please select)

  Select Animal/insect Blood/body substance Building fixtures Electricity/Gas Electrical appliance Environmental factors Equipment (eg.Playground) Fire/explosion Floor/ground Foreign object (eg. splinter) Furnitue Machinery (fixed) Machinery (mobile) Non powered tool Person/people Stairs/steps Stress/trauma Sunburn/UV radiation Temperature Travel Radiation/arc flash Virus/disease Water/pool Working/learning environment other

  • Animal/insect
  • Blood/body substance
  • Building fixtures
  • Electricity/Gas
  • Electrical appliance
  • Environmental factors
  • Equipment (eg.Playground)
  • Fire/explosion
  • Floor/ground
  • Foreign object (eg. splinter)
  • Furnitue
  • Machinery (fixed)
  • Machinery (mobile)
  • Non powered tool
  • Person/people
  • Stairs/steps
  • Stress/trauma
  • Sunburn/UV radiation
  • Temperature
  • Travel
  • Radiation/arc flash
  • Virus/disease
  • Water/pool
  • Working/learning environment
  • other

• Associated equipment?

• When was the hazard identified?

  Date

• Who identified the hazard?

• The potential for serious injury was:

  Low

  Medium

  High

• Please take a photo if necessary:

  Media

9. DETAILS OF WITNESS (if not staff please provide address and phone number below)

• Please select:

  Staff member

  School student/Class

  Other person eg. Volunteer

• Details if staff or student

• Full Name:

• Student ID (if known)

• If there are other significant witness's please complete below:

• Signature of person completing audit:

  Sign

• Select date

  Date

• Name/Job Title

10. INCIDENT REFERRED (MANDATORY)

• Referred to:

• To be completed by either WHSO, Head of Dept

• Follow up:

• Work cover claim?

  Yes

  No

  N/A

• Possible legal actions?

  Yes

  No

  N/A

• Is this a 'notifiable' incident according to WH&S Act 2011?

  Yes

  No

  N/A

FURTHER ACTIONS

• 1. Consult the School WHSO on hazard details and the recommended control strategies. 2. place the original incident report on file at clinic after being signed by WHSO. 3. Note: a copy of a student incident report may be provided to the student/parent/caregiver on request through the Principal. Details of other parties ( eg. Other students names) should be obscured.