Information
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Document No.
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Incident Location
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Conducted on
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Prepared by
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Signature
1. INJURED PESON'S DETAILS
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INJURED PERSON.
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Full Name:
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Association with school:
- Student
- Parent
- Public
- Visitor
- Volunteer
- Other
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Student ID (if known)
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Address: (if not staff/ student)
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Suburb: (if not staff/ student)
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Post Code: (if not staff/ student)
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Phone: (if not staff/ student)
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Emergency Contact Name (if known) (if not staff/ student)
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Emergency Contact Number (if known) (if not staff/ student)
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Why on school property: (if not staff/ student)
2. REPORTING PERSON OR FIRST AID ATTENDANT
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Whether its a staff or other person (if not staff please provide address and phone number )
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Full Name:
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Department:
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Address (only if NOT staff)
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Phone Number (only if NOT staff)
3. WHAT HAPPENED ?
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Detailed description of incident ( consider the activity, what happened and why)
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Provide more details if necessary:
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Add/take picture of incident for record
4. INCIDENT INFORMATION
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ACTIVITY - What was the activity at the time of the incident ?
- 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)
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CAUSE - What caused the injury?
- 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
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SEVERITY ( FILL OUT MAJOR INCIDENT FORM IF NOT MINOR)
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TREATMENT REQUIRED
- Nil
- First Aid (at incident location)
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If first aid - what first aid was provided?
5. INJURY / ILLNESS DETAILS
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Injury / Illness
- Ache/Pain
- Bite/Sting
- Bruise/crush
- Bump/Knock
- Cut/laceration
- Headache
- Irritation/Allergy
- Respiratory
- Sprain/strain
- Stress reaction
- Other
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Location on the Body
- 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:
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Sign - Reporting person or First Aid attendant
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Sign - Injured Person
6.CAUSE OF ILLNESS/INJURY
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Was the injury/Illness caused by a confrontation or aggressive act?
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If aggressor?
- Parent
- staff
- volunteer
- primary student
- secondary student
- Visitor
- other
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Type of confrontation?
7. HAZARD INFORMATION/MANDATORY (if necessary seek assistance from school WHSO to determine the hazard)
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What was the primary hazard that caused the incident?
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Contributing Hazard Category (please select)
- Animal/insect
- Blood/body substance
- Building fixtures
- Electricity/Gas
- Electrical appliance
- Environmental factors
- Equipment
- 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
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Associated equipment?
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When was the hazard identified?
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Who identified the hazard?
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The potential for serious injury was:
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Please take a photo if necessary:
8. DETAILS OF WITNESS (if not staff please provide address and phone number below)
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Please select:
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Details if staff or student
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Full Name:
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Student ID (if known)
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If there are other significant witness's please complete below:
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Signature of person completing audit:
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Select date
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Name/Job Title
FURTHER ACTIONS
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1. Update team on incident 2. Update any corresponding SOP's on new procedures to avoid incident again 3. Record in Injury Register.
